Ontario's Response to Listeriosis Outbreak Worked Well But More Clarity of Roles Needed



    Chief Medical Officer of Health Releases Report on 2008 Listeriosis
    Outbreak

    TORONTO, April 17 /CNW/ -

    NEWS

    Ontario's public health system detected the 2008 listeriosis outbreak
swiftly, but more needs to be done to clarify roles and responsibilities at
the federal and provincial levels to better manage foodborne outbreaks in the
future, says Ontario's Chief Medical Officer of Health.
    In a report on the 2008 listeriosis outbreak, Dr. David Williams says
that cross-jurisdictional outbreaks are more complex to investigate than
localized outbreaks. They require different epidemiological and food source
identification strategies. They rely more heavily on complex new laboratory
testing technologies. They also involve more partners and more communication.
    The Chief Medical Officer of Health says that four key steps are required
to strengthen Ontario's - and Canada's - capacity to respond to provincial and
cross-jurisdictional foodborne outbreaks:

    1. Clarify Roles and Responsibilities in Outbreak Management

    Public health should take the lead in outbreak management. In the event
of a provincial outbreak, the provincial Chief Medical Officer of Health
should establish an Outbreak Coordinating Committee whose mandate is to
provide him/her information and advice to manage the outbreak.
    In the event of a suspected or declared national/international outbreak,
the federal Chief Public Health Officer should establish a National Outbreak
Coordinating Committee (NOCC), which would include all the
provincial/territorial Chief Medical Officers of Health.

    2. Strengthen Laboratory Capacity

    The newly created Ontario Agency for Health Protection and Promotion
(OAHPP) should develop a plan to increase the public health laboratories'
capacity to conduct a wider range of tests, monitor strains of bacteria and
other organisms that pose a threat to public health, and educate public health
units about sampling techniques.
    The federal government should review the existing strategic approach to
advanced molecular testing, addressing such items as the acceptable turnaround
time for lab results (including transportation), the ability to address higher
demand for molecular testing, and the importance of having appropriate
alternatives should the National Microbiology Lab not be available.

    3. Enhance Ontario's Capacity to Detect Foodborne Outbreaks

    Ontario is now better able to detect non-localized foodborne outbreaks
thanks to the introduction of electronic case management systems. For the
surveillance system to be fully effective, public health units must provide
timely, complete data, and the public health system must have the skilled
staff and other resources to investigate any signs of a possible outbreak.

    4. Improve Communication

    Effective, clear and timely communication is essential in managing a
foodborne outbreak and in maintaining public confidence. During
cross-jurisdictional outbreaks, partners must work closely together to
coordinate communications.
    The Chief Medical Officer of Health or designate should be the official
media spokesperson during a provincial outbreak. Similarly, the federal Chief
Public Health Officer or designate should be the official media spokesperson
for the federal government during a national outbreak.

    QUOTES

    "Cross-jurisdictional outbreaks, such as the listeriosis outbreak last
year, are likely to become more common because of the trend to large-scale
food manufacturing and processing," said Dr. David Williams, Ontario's Chief
Medical Officer of Health. "While Ontario's public health system worked well
in detecting the outbreak, we need to have better clarity of roles and
coordination to more effectively manage future outbreaks."

    QUICK FACTS

    
    -  A listeriosis outbreak began in the summer of 2008 and ended in
       December, affecting people in seven provinces across Canada (Ontario
       was the hardest hit with 41 of the 56 cases and 16 of the 22 deaths).
    -  Most of the Ontarians who fell ill were elderly (mean age was 78) and
       88 per cent were either living in a long-term care home or
       hospitalized before they became ill.

    LEARN MORE

    Read the report
    Read more about Key Findings and Recommendations from the Report
    Learn more about Operation Health Protection
    (http://www.health.gov.on.ca/english/providers/project/ohp/ohp_mn.html).

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    BACKGROUNDER
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                         OPERATION HEALTH PROTECTION

    Operation Health Protection - a three-year action plan introduced by the
Ontario government in 2004 - has resulted in significant improvements to the
province's public health system. Key accomplishments include:

    Enhancing Infectious Disease Prevention, Detection and Control

    The government has taken a number of steps to better protect the public
against infectious and communicable diseases. These include:

    -  Implementing the integrated public health information system (iPHIS)
       where information is electronically collected, transmitted and
       analyzed, allowing public health units to identify and track unusual
       and unexpected instances of infectious diseases. IPHIS proved to be a
       valuable resource in helping to track the 2008 listeriosis outbreak
    -  Establishing the Provincial Infectious Diseases Advisory Committee
       which provides expert advice on prevention, surveillance and control
       measures
    -  Creating 14 regional infection control networks across the province to
       coordinate infection prevention and control activities, and support
       standardized practices in health care facilities
    -  Funding 166 infection prevention and control practitioners (ICPs) in
       hospitals and public health units across the province. An ICP is a
       health care professional with specialized training and expertise in
       infection prevention and control who works with all departments to
       prevent health care-acquired infections through planning, implementing
       and evaluating current practices.
    

    Creating the Ontario Agency for Health Protection and Promotion

    The Ontario Agency for Health Protection and Promotion is the province's
first-ever arms-length public health agency.
    The agency provides technical expertise and advice to frontline health
care workers, public health units and government by translating research and
information into practical tools. It also helps to enhance the public health
system's emergency response capability.

    Upgrading and Renewing the Ontario Public Health Laboratories

    The Ontario Public Health Laboratories (OPHL) are being modernized and
strengthened with the acquisition of a new laboratory information system. Over
the last two years, new medical and scientific staff have been recruited
nationally and internationally to strengthen the OPHL's capacity as the labs
became aligned with the Ontario Agency for Health Protection and Promotion.

    Increasing Public Health Funding

    The government increased its share of funding for mandatory programs
delivered by the 36 public health units to 75 per cent in 2007 from 50 per
cent in 2004.

    Improving Health Emergency Preparedness

    The Ministry of Health and Long-Term Care created the Emergency
Management Unit (EMU) to lead and support emergency management activities for
the health system. The EMU has become a centre of leadership and expertise in
the area of health emergency management, with much of Ontario's work being
held up as a model in other jurisdictions. The EMU has been instrumental in
leading pandemic preparedness for the health sector and developing the public
health emergency standard as part of the Ontario Public Health Standards.

    
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    BACKGROUNDER

    CHIEF MEDICAL OFFICER OF HEALTH'S REPORT ON THE MANAGEMENT OF THE 2008
                       LISTERIOSIS OUTBREAK IN ONTARIO

                   Summary of Findings and Recommendations

    1. Detecting the Outbreak

    In 2005, Ontario implemented the integrated Public Health Information
System (iPHIS), a web-based system, which all public health units use for
reportable infectious disease surveillance and case and contact management.
Each health unit is required to enter case information on all reportable
diseases in its jurisdiction into iPHIS. Staff at the Ministry of Health and
Long-Term Care analyze data from iPHIS daily supported by a program called
Early Aberration Reporting System (EARS), which detects statistical increases
in the number of cases above the norm.
    The iPHIS and EARS systems aided in the detection of the province-wide
listeriosis outbreak. The EARS flags alerted staff to a higher number of cases
than usual. As a result, staff was quick to consider the possibility of a
wider outbreak. Without iPHIS, the small number of initial cases across the
province might never have been linked together and the outbreak might not have
been detected until many more people had fallen ill.
    The ministry has refined its process for investigating and responding to
EARS flags, but more can still be done to assess the sensitivity and
specificity of EARS in detecting outbreaks.
    Although the iPHIS system works well, there is sometimes a lag between the
time a public health unit is aware of a case and the time that data on the
case are entered into iPHIS. In some cases, health units do not initially
enter enough information for ministry staff to be able to identify possible
links.
    During the investigation, the ministry reminded health units to enter
listeriosis cases within one business day of receiving the initial
notification from a health care facility or laboratory, and to provide more
information about each case. As a result, the ministry was able to identify
that a larger number of cases than originally suspected. The information on
these cases helped identify the outbreak and guide the investigation.
    Timely and complete reporting is crucial in detecting outbreaks. The
system would be more efficient if all health units routinely entered cases
quickly and provided complete surveillance data.

    Recommendations
    ---------------
    To continue to build the province's capacity to detect future
province-wide outbreaks:

    1.1 Local public health units should:
    -  enter cases of high risk disease, such as listeriosis, into iPHIS in a
       timely way (i.e., within 1 business day)
    -  provide adequate case information to support provincial analysis and
       investigation.
    

    1.2 The ministry should ensure that Public Health Division and local
health units have the skilled staff and other resources to provide timely
data, and investigate and respond to any aberrations identified in
surveillance data in iPHIS and other electronic systems.

    1.3 The MOHLTC should review the sensitivity and specificity of EARS
flags and develop an algorithm that defines the steps to assess the follow-up
action to be taken in response to EARS flags.

    2. Confirming the Outbreak

    Given the non-specific symptoms of listeriosis and the relatively small
number of people who fall ill from listeriosis, laboratory testing is
essential to help identify and confirm an outbreak.
    Molecular typing was critical to investigating the 2008 listeriosis
outbreak. It allowed investigators to compare human and food samples, and
identify the probable source of the outbreak.
    Listeria testing expertise has been centralized at two federal
laboratories: the National Microbiology Laboratory in Winnipeg and the
National Listeria Reference Laboratory in Ottawa. During the 2008 listeriosis
outbreak investigation, all molecular typing was conducted by the two federal
laboratories, which were responsible for responding to requests from across
the country.
    The molecular typing provided by the National Microbiology Laboratory for
human samples and by the Listeria Reference Laboratory for food samples helped
confirm that the cases across the country were linked, and that the source of
the contamination was the luncheon meats from the Maple Leaf Foods plant.
    This reliance on a single laboratory for all molecular typing may no
longer be sufficient as typing becomes more integrated into the testing menu.
    At the beginning of the 2008 outbreak, molecular typing of Listeria
monocytogenes was not available at the Ontario Central Public Health
Laboratory, but it was subsequently introduced. If the Ontario Central Public
Health Laboratory had conducted the molecular typing in its own laboratory,
the time required to transport the samples and request the tests could have
been eliminated, and the time it took to obtain test results might have been
reduced by, at most two to three days. Testing process and protocols will
still take time (i.e., about 12 days) and the Central Public Health Laboratory
will still have had to send its molecular typing results to the National
Microbiology Laboratory for cross referencing with molecular typing results
from other provinces. Consideration should be given by the federal government
to the need for greater regional capacity as molecular typing moves from a
research tool into more standardized usage. Further, reliance on a single
laboratory for advanced testing may compromise time frames for testing in some
areas of the country.
    At the time of the outbreak, Ontario's public health laboratories did not
have a fully integrated laboratory information system. Ontario would be able
to respond more quickly to outbreaks if it had an information system that
could integrate public health surveillance data and laboratory testing data.

    Recommendations
    ---------------
    In December 2008, the newly created Ontario Agency for Health Protection
and Promotion (OAHPP) assumed responsibility for the operation of the
province's public health laboratories. To address gaps identified during the
2008 listeriosis outbreak and enhance Ontario's capacity to investigate and
confirm outbreaks:

    2.1 The OAHPP should ensure that partners are aware of the requirements
for specimen collection and submission, which will lead to more timely
processing of tests and communication of laboratory data to all outbreak
partners.

    2.2 OAHPP should ensure that Ontario has 24/7 capacity within its own
laboratory system to conduct the tests required to detect and respond to
foodborne outbreaks, thereby reducing its reliance on federal agencies.
Predetermined testing protocols should be established for outbreaks that
require federal agency lab support.

    2.3 OAHPP should develop a coordinated system to monitor strains of
bacteria and other organisms identified as public health priorities in human,
food and environmental samples, including maintaining a database of strain
patterns that can assist in investigating future outbreaks.

    2.4 OAHPP should establish a working group (including representatives
from federal partners) to:

    
    -  identify any potential to improve testing timelines in the province
    -  develop a plan to enhance Ontario's laboratory capacity and reduce its
       dependence on federal agencies
    -  define laboratory roles and responsibilities for sample testing during
       foodborne outbreak
    -  report back to the Chief Medical Officer of Health with
       recommendations.

    2.5 The federal government should:
    -  review the existing strategic approach to advanced molecular testing,
       addressing such items as the acceptable turnaround time for lab
       results (including transportation), the ability to address anticipated
       higher demand for molecular testing, and the importance of having
       appropriate alternatives should the NML not be available.
    

    3. Managing the Outbreak

    Information is the most important asset during an outbreak investigation.
During the investigation the Canadian Food Inspection Agency (CFIA) - the lead
federal agency for food recalls - was the sole intermediary between Maple Leaf
Foods and the public health officials responsible for investigating the
outbreak. Toronto public health inspectors were not able to enter the plant
until almost three weeks after CFIA first identified Maple Leaf Foods as the
manufacturer of the food that tested positive for Listeria.
    Although the Ministry of Health and Long-Term Care asked the CFIA for
comprehensive information on the distribution of the products implicated in
the outbreak, this information was never received. As a result, it was not
until August 14th that public health officials were informed that contaminated
products might have been distributed to restaurants and August 17th that they
were informed that contaminated products might have been distributed to some
retail stores and deli counters. During the investigation, they were not able
to obtain complete information on the number or location of establishments in
Ontario that had received products implicated in the outbreak. If public
health authorities had had timely access to this information, they might have
been able to take additional targeted steps to reduce possible exposure among
the general public. The lack of information about the national distribution of
affected products also hampered the national investigation of the outbreak.
    No mandatory food recall was issued by CFIA; however, Maple Leaf Foods
issued a voluntary recall that started with two products and expanded to over
220 products made in the same plant.
    Over a period of about two weeks after the outbreak was declared, the
CFIA health hazard alerts expanded in scope (number of products) and extent
(number of retail sites). Each day, new products were announced as posing a
risk.
    The ever-expanding list of products and stores affected created the
impression that the response was not well organized, and contributed to the
public's sense of unease and confusion. It also made it more difficult for
public health units to plan and organize their efforts to monitor the
effectiveness of product recalls.
    The handling of food recalls highlighted the management and coordination
challenges of an outbreak that involves federal, provincial and local
partners, particularly when roles and responsibilities are not clear.
    Given large-scale manufacturing and processing of food and complex food
distribution networks, Ontario and Canada are likely to see more non-localized
outbreaks of foodborne illnesses. The current processes and structures for
investigating and managing outbreaks are not adequate to support a coordinated
response among different jurisdictions and levels of government. Roles and
responsibilities at the federal, provincial and local levels are not clear.
    It was not clear to the partners which responsibilities rested with the
Public Health Agency of Canada (PHAC) and the federal Chief Public Health
Officer, and which ones with the Chief Medical Officer of Health in Ontario.
It was also not clear whether the lead federal agency was PHAC or the CFIA, or
to what extent local medical officers of health or the Chief Medical Officer
of Health in Ontario could act alone to protect public health.

    Recommendations
    ---------------
    To enhance the capacity of all provinces and territories to manage
provincial/territorial foodborne outbreaks:

    3.1 In the event of a suspected or declared provincial/territorial
outbreak, the provincial/territorial Chief Medical Officer of Health should
establish and chair a provincial/territorial Outbreak Coordinating Committee
(OCC) to provide him/her information and advice in managing the outbreak. The
terms of reference of the OCC should explicitly require:

    
    -  a mandate to protect public health as the overarching priority
    -  the participation of all lead provincial and federal food inspection,
       regulation and public health agencies, including laboratories
    -  all agencies within the province/territory to fall under the
       leadership of OCC
    -  open disclosure of all data and information from all participating
       agencies
    -  the provincial/territorial Chief Medical Officer of Health to be the
       spokesperson for the OCC
    -  the operation of the OCC to be consistent and, when required,
       integrated with existing provincial/territorial emergency response
       plans, the revised FIORP and other provincial/territorial outbreak
       response plans.
    

    To enhance the capacity to manage a national or international foodborne
outbreak:

    3.2  In the event of a suspected or declared national/international
outbreak, the federal Chief Public Health Officer should establish and chair a
National Outbreak Coordinating Committee (NOCC). The terms of reference of the
NOCC should explicitly require:

    
    -  a mandate to protect public health as the overarching priority
    -  the participation of the Chairs of the provincial OCCs and the leads
       of federal food regulation, inspection and public health agencies,
       including laboratories
    -  the Chief Federal Public Health Officer to be the spokesperson of the
       NOCC
    -  the existence of the NOCC to not compromise the mandate, role and
       primacy of the provincial/territorial OCCs in outbreak management.

    To enhance Ontario's capacity to manage provincial outbreaks:

    3.3 Both the Canada Foodborne Illness Outbreak Response Protocol (FIORP)
and the Ontario Foodborne Health Hazard and Illness Outbreak Investigations
Memorandum of Understanding (Ontario MOU) should be reviewed at the provincial
and federal levels to make certain the documents take into account large-scale
manufacturing practices and that the protocols and processes set out clear
roles and responsibilities, and will ensure a timely, effective and
coordinated response to a foodborne outbreak; they should then be put into
operation.

    3.4 The Chief Medical Officer of Health for Ontario should develop
Ontario-specific guidelines for the management of foodborne outbreaks and
provincially initiated food recalls, food seizures, and other activities that
may be required under the HPPA. The guidance document should:

    -  reinforce Ontario's statutory authority to manage a provincial
       outbreak and protect public health even if that means acting
       independently from other provincial and federal partners (i.e., when
       the evidence that public health requires to act may not meet the CFIA
       criteria to issue a food recall)
    -  use the protocols within existing Ministry of Health and Long-Term
       Care and Public Health Division emergency response plans as the basis
       for outbreak management guidelines
    -  set out the criteria to change a local outbreak to a provincially
       managed outbreak
    -  establish a framework and structure for managing a provincial outbreak
       that is consistent with existing provincial protocols and agreements
       with local heath units
    -  identify the criteria/triggers that will be used to:
       -  issue orders to address health hazards related to foodborne
          outbreaks
       -  declare a possible or probable provincial outbreak
       -  encourage a federal or industry-led food recall
       -  implement a public communications plan.
    -  provide guidelines for investigating listeriosis and other reportable
       foodborne illnesses, including sampling protocols and methodologies to
       be used during provincial outbreaks
    -  include guidelines on issuing and enforcing orders for holding,
       disposing of or returning suspect food items to a plant; and processes
       to monitor the effectiveness of a food recall
    -  establish requirements for regularly reviewing and updating the
       guidance documents.
    

    3.5 The Chief Medical Officer of Health for Ontario should encourage
training and tabletop exercises for all partners to test the protocols and
processes for managing a cross-jurisdictional outbreak.

    3.6 All public health units in Ontario should maintain 24/7 capacity to
monitor outbreak communications, including food recall notices, and develop
on-call systems that ensure any notices received after hours are read within
two hours of being issued.

    4. Communications

    During the outbreak, each organization and each level of government
handled public communications within their respective jurisdictions. Public
health units provided information to their local media. The Ministry of Health
and Long-Term Care managed communications to the media and the general public
in Ontario. The PHAC and the CFIA were responsible for communications at the
national level. Communications were not well coordinated among these different
levels of government.
    The lack of coordination contributed to public confusion and created the
impression that the outbreak was not being well managed, which affected public
trust and confidence in the public health system.
    The lack of coordination was due in part to the different levels of
evidence required by different partners to trigger action, but it was also due
to the fact that the Office of the Chief Public Health Officer at the PHAC did
not appear to have a clear mandate for leadership in a cross-jurisdictional
foodborne outbreak.

    Recommendations
    ---------------

    To enhance the capacity to communicate during an outbreak:

    4.1 All organizations involved in managing a foodborne outbreak should
adopt the 24-hour information cycle that is an integral part of all Ontario
emergency response plans.

    4.2 Communications to health care practitioners should be timely and
efficient to ensure that people are diagnosed and treated quickly and
effectively.

    4.3 The Chief Medical Officer of Health or designate should be the
official media spokesperson for a provincial outbreak, and adhere to the
24-hour information cycle when speaking to the media.

    4.4 The Federal Chief Public Health Officer or designate should be the
official media spokesperson for a national outbreak.

    4.5 To improve the accuracy of reporting, the MOHTLC and OAHPP should
educate the media about epidemiological and laboratory testing methods used
during a foodborne outbreak and how data are interpreted.

    4.6 The MOHLTC should develop standard fact sheets that can be adapted
and distributed quickly in the event of a foodborne outbreak. Communication
staff should be involved early in the outbreak response so any communications
issues can be resolved quickly and the MOHTLC should establish a streamlined
approval process for communications during an outbreak.

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For further information:

For further information: Mark Nesbitt, (416) 314-6197

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Ontario Ministry of Health and Long-Term Care

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