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A historical perspective on outbreaks, illnesses and incidents
BCCDC Environmental Health Seminars April 24, 2012
Lorraine McIntyreFood Safety Specialist, Environmental Health ServicesBC Centre for Disease Control
"Those who cannot remember the past are condemned to repeat it."
Describe the event
Focus on the outcome
Explore how these events became a driver for change
Changes in Regulations and Guidelines
Changes in Consumer Behaviour
Industry Improvements
J Food Prot. 2004 Jun;67(6):1111-5. and Epidemiol Infect. 2005;133(5):809-16.http://www.gazette.gc.ca/archives/p2/2004/2004-12-15/html/sor-dors280-eng.html
ILLNESSES 2003
2 children, both hospitalized
OUTCOMES
Media & scientific attention
Coincided with meat regulation
amendments
2003 Box of Chicken Strips from Food Poisoning Investigation
2005 Box of Chicken Nuggets from the same company
1980’s – the decade of botulism
Commercial product: • Alaskan canned salmon
recalls (1982)• 1 death (Belgium)
Home canned products: • 5 outbreaks (1982 to
1984)
Restaurant outbreaks: • garlic-in-oil (1985)• bottled Chanterelle
mushrooms (1987)
Chopped garlic in soybean oil at a family restaurant (1985)
OUTBREAK –Type B Botulism
• 2nd largest outbreak of botulism in North America
• 37 ill, no deaths (7 required ventilation) cases in Canada, US, NL
Foods implicated
• Beef dip, steak sandwich, garlic buttered bread.
• Dessicatedgarlic rehydrated in soybean oil; shipped refrigerated & labelled as “keep refrigerated”.
Issues at restaurant:
• Not refrigerated, left on shelf 8 months
• pH >4.6 (range 4.6 to 5.7)
1. Ann Intern Med. 1988 Mar;108(3):363-8.2. Canada Diseases Weekly Report. 1985;12(13):53.
3. MMWR Morb Mortal Wkly Rep. 1985 Oct 18;34(41):643.
Bottled mushrooms at a fine-dining restaurant (1987)
OUTBREAK –Type A Botulism
• 6 ill (31 exposed), no deaths (5 hospitalized, 3 ventilated)
Foods implicated
• Fricassee de Rouget-Barbet and Lobster with Wild Mushrooms
• Chanterelle mushrooms
• Mushrooms from Van. Isl.
Issues at restaurant:
• Canning procedure
• pH 5.2, room temperature storage
1. MMWR Morb Mortal Wkly Rep. 1987 Feb 27;36(7):103. 2. Canada Diseases Weekly Report. 1988;14(10):41-2. 3. Canada Diseases Weekly Report. 1987;13(8):35-6.
Multiple hurdle concept
Food Control. 1990:139-41.Am J Public Health. 1990 Nov;80(11):1372-3.
US OUTBREAK -3 ill1989 NY dinner party–also garlic in oil.
• Multiple barriers: pH,refrigeration
• No non-commercial canned foods in restaurants
• Laboratory service in BC• HLBC file on how to
avoid botulism in home canning
OUTCOMES
OUTBREAK
• 143 ill with E.coli O157:H7
• 30% hospitalized
• 4% HUS• 47 cases of
Yersiniaenterocolitica
Foods implicated
• Hungarian salami
• Cervalet salami
Issues at Processing Plant
• Company followed the HACCP plan
First CFIA recall based on epi-evidence
• Product Recalls – CFIA/HC another 1st
•HC Guideline no. 12•Heat• 5D reduction• End-product testing•HACCP, raw product testing and 2D reduction•Alternative evaluation
• PFGE, Pulsenet Canada
OUTCOMES
MMWR Morb Mortal Wkly Rep. 1998 Jun 12;47(22):457-62.
OUTBREAK
• 209 illnesses• July 1st – Sept 26, 1997• MHO bans shellfish sales in all
restaurants• DFO closes coast to harvesting
MMWR Morb Mortal Wkly Rep. 1998 Jun 12;47(22):457-62.
OUTCOMESIntergovernmental Shellfish
Stakeholder Group, and
PRISC
Risk reduction strategy
Indicator sites,
monitoring by CFIA
New Industry Controls
Temp control Labelling
CFIA Laboratory
PCR method (2006)
Health Canada
Retail level for Vp(2008)
Foodborne Pathog Dis. 2007 Fall;4(3):349-58.http://www.inspection.gc.ca/english/fssa/fispoi/man/cssppccsm/facfere.shtml
OUTBREAK
• 79 illnesses• Multiple genogroups, genotypes• No point source contamination
OUTCOMES
Harvesting guidelines and emergency closure plans•extreme weather events •wastewater treatment
failure, conditional management plans
• "facts on shellfish harvest area closures related to significant weather events"
Methods•NEW detection method
for norovirus in oysters (OPFLP-01 in HC Compendium)
•Round robin trials (Mattison et al, 2009)
Health Canada•Health risk assessment•Retail guidelines?
Provincial Health•VCH menu warnings•Consumer brochures
Mattison K, Grudeski E, Auk B, Charest H, Drews SJ, Fritzinger A, et al. Multicenter comparison of two norovirusORF2-based genotyping protocols. J Clin Microbiol. 2009 Dec;47(12):3927-32.
http://www.bccdc.ca/foodhealth/fish/default.htm
Listeria monocytogenes 2002 BC Outbreaks
Both outbreaks caused by combination of:Inadvertent mistake/circumstance(s), AND
Deliberate change in procedures by operator
Jan 2002
48 ill
•43 febrile gastroenteritis
•3 meningitis 2 bacteremia
Source, spray bottles
Nov 2002
82 ill• All febrile
gastroenteritis
Source, water
Listeria monocytogenes 2002 BC Outbreaks
OUTCOMES:
Testing of SMR cheeses
Proposed changes to Dairy
regulations
Dairy workers’ course revisions
Stool testing for febrile
gastroenteritis
"Those who cannot remember the past are condemned to repeat it."
How we changed the world
Share your stories
If you see something,
say something
Acknowledgements
Federal services• Terry Peters• Carol Crawford• Karen Catherwood• Barry Morgan• Jerry Hirsch• Jennifer Liu• Deirdre Kelly• Dave Graham• Lance Hill• Pascal Delaquis• Rick Szabo• Kevin Carlisle• Bill Slater
Provincial and Regional services • Laura Macdougall• Lynn Wilcott• Sion Shyng• Elsie Friesen• Shendra Brisdon• Joe Fung• Julie Wong• Ana Paccagnella
Industry
• Marty Wilder (FPAC)
Outbreaks Affecting Policy
Nyall Hislop M.Sc., CPHI(C)Senior Advisor, Safe Food Program
Environmental Health Officer IIIAlberta Health Services
Edmonton Zone
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History
There have been many instances…
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Number one…
Calgary 2010 • Incident An outbreak of Salmonella involving 91 confirmed
cases Initially implicated uninspected eggs used by a
commercial food establishment supplying “lunch trucks”
• Highlighted difficulties with Tracking Identification
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Outcomes
• Decal for each truck
• Expanded– Self-contained mobiles– Water haulers– Carts
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Number two…
• Donair / Shawarma outbreaks in Edmonton and Calgary– E.coli O157:H7 and Salmonella
– Both local and Federal producers implicated
– Resulted in the formation of a FPT working group which conducted a comprehensive hazard assessment, engaged stakeholders (industry & regulators) and eventually released Federal guidelines.
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In Alberta
• Roll out– Occurred in advance of Health Canada’s final
recommendations– Several “town hall forums” for manufacturers and
retailers– Delivery and discussion of standards during approval
and monitoring inspections– “After-hours” and “mystery shopper” inspections
– Enforcement
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Newspaper (fine)
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Number three…
• AHS has a Public Health Epidemiologist who oversees outbreaks
• 2003-2007 (Edmonton Zone)
• 31 of 78 outbreaks investigated by EPH implicated infected food handlers as the most likely source (40%)
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Actions
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How can duplicate it here?
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Action
• Drafted guidelines / public resource materials – Explained issue– Tied new requirements to existing
sections of the Public Health Act • Food Regulation
• Communicable Disease
Regulation
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Focused on Key Messages
Vomiting / Diarrhea / Jaundice
• Exclude until symptoms resolve– Notify manager– Don’t come to work,
– Don’t schedule for work,
– Go home if onset occurs at work– See a doctor
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Key Messages
ILI
• Information on transmission• Encourage owners to restrict at minimum
Cuts / Sores / Skin Conditions
• PPE or restricted duties
Blood borne Pathogens
• Information highlighting universal precautions
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Roll out
• Targeted medium and high risk food establishments
• Guidelines delivered and explained during monitoring inspections
• EIP added to the set criteria for monitoring inspections (re-enforced and evaluated at each monitoring inspection)
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Outcomes
• 9 food establishments cited for not having an EIP in place during 2011 (0.14%)
• Improved industry awareness
• Reduction in employee illness related outbreaks??
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Donairs: From Outbreak to Policy
BCCDC Environmental Health Seminar
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Donair Associated Outbreaks in Canada
Beef Donair - Calgary – September 2004:84 cases of E. coli O157:H7 (43 confirmed / 41 probable)8 hospitalizations and 2 cases of H.U.S.Chicken Shawarma - Windsor – 2005:18 confirmed cases of salmonella (46 reported illnesses)Beef Donair - Edmonton – May 2006:9 confirmed cases of E. coli O157:H7 during Oilers Stanley Cup runBeef Donair - Alberta – November 2006:14 confirmed cases of E. coli O157:H7 (2 hospitalizations)Product made at federally registered plant – class 1 recall
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Donair Associated Outbreaks in Canada
Chicken Shawarma – Edmonton – May 2007:2 confirmed cases of Campylobacter
Chicken Shawarma? – Niagara – June 2007:
Beef Donair – Edmonton – September 2007:6 confirmed cases E. coli O157:H7 (2 hospitalizations)
Chicken Shawarma – Edmonton – November 20072 confirmed cases of Campylobacter
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Formation of the Policy Team
• Alberta Health and Wellness approached Health Canada and FPT Committee for input• Issue had not been previously studied in-depth • What we knew:
- Produced in CFIA plants, provincial plants, and retail facilities throughout Canada- Traditional product served in many other countries - Confirmed source of a major E. coli outbreak- Cooking and serving method was unique
• The issue would likely require a multi-jurisdictional effort
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Donair Working Group Members:
• Health Canada • Public Health Agency of Canada• Canadian Food Inspection Agency • Alberta Health and Wellness • Calgary Health Region• Capital Health (Edmonton)• BC Centre for Disease Control• Nova Scotia Agriculture & Fisheries
• Ontario Ministry of Agriculture & Food
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Working Group Objectives
1. evaluate current Canadian processing, preparation, and handling procedures for donairs prepared at both manufacturing facilities and at food service
2. evaluate relevant Canadian and international research, reported food-borne disease outbreaks and existing guidance to industry
3. identify the food-borne illness risks associated with these products
4. develop recommendations for their safe processing, cooking and handling
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Product Characteristics
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Policy Development Timeline
2005: Policy team formedCalgary and Edmonton Health Regions implement mandatory requirements for a secondary cooking step
2006: Issue Identification Document Completed- product characterization- risk factors for cone production, cooking and serving, cooling and storage identified
2007: Alberta-wide requirements in place National consultation on draft recommendations
2008: Niagara Health region requirements in placeFinal recommendations accepted by FPT CommitteeImmediate implementation in a number of jurisdictionsSimultaneous publication of final policy and consultation report on Health Canada’s website
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Canadian Media Coverage
• Ottawa Citizen: September, 2007• CBC Radio Interview: September, 2007• Halifax Chronicle – Herald: November, 2007
o ‘You may want to re-think that late-night donair’o ‘N.S. donairs; They induce babies, upset tummies and make us
homesick’• Global News Interview: December, 2007• CTV Halifax Interview: January, 2008• Halifax Chronicle – Herald: March, 2008
o ‘Donair Safety Report on the way’• Edmonton Journal: March, 2008
o ‘Donair beefs rooted in Oiler mania’
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International Media Coverage
June 2005: “Doner kebabs safer than ever following State Government campaign (NSW)”
Sep. 2006: “£300K for my Kebab poisoning” (UK)
Nov. 2006: “Kebab shop owner forks out over food poisoning outbreak” (UK)
Mar. 2007: “Germany offers courses in kebab production”
June 2007: “Shawarma shops face clamp” (Bahrain)
Aug. 2007: “Jordan bans chicken shawarma sale after hundreds of salmonella poisoning cases”
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Final Policy
• Management of the Risks Related to Consumption of Donairs and Similar Products (Gyros, Kebabs, Chawarmas, and Shawarmas) - May, 2008http://www.hc-sc.gc.ca/fn-an/legislation/guide-ld/manage_ris_donair-eng.php
• Illness risks and outbreak data included
• Recommendations for donair cone production, cooking and serving (secondary cook), and cooling and storage.
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Thank You
Donair Policy Working Group- Bill Slater, Lance Hill, Denise Oudit (HC)- Mark Fehr (AHS)- Nyall Hislop (AHS)- Doug Everett (AHW)- Sion Shyng (BCCDC)- Marsha Taylor (PHAC)- Negha Yahya (OMAF)- Rosemary Arsenault (NS Agriculture)- Connie Zagrosh (CFIA)
Improving the Safety of Raw Ground Beef
BCCDC Environmental Health Seminar
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1992 and 1993
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HC Guideline No. 10, March 1999Recommended action when ground beef is tested for E.coli O157:H7
Product E.coli O157:H7 Level of Generic E.coli in Ground Beef Recommended Product Action Follow-up
Ground Beef Detected Not done Recall to consumer level GMP/HACCP review
Detected >100cfu/g inany of five sample units per lot
Recall to consumer level GMP/HACCP review
Detected ≤ 100cfu/g in five sample units per lot Recall to retail level GMP/HACCPreview
Not detected >100cfu/g in any of five sample units per lot No action GMP/HACCP review
Not detected ≤ 100cfu/g in five sample units per lot No action Not required
Recommended action for ground beef derived from trimmings, beef carcasses or an equipment surface in direct contact with ground beef which has been found positive for E.coli O157:H7
Product Level of Generic E.coli in Derived Ground Beef Recommended Product Action Follow-up
Ground Beef derived from trimmings, carcasses or an equipment surface that tested positive for E.coliO157:H7
>100cfu/g in one or more of five random samples of ground beef derived from positive product
Recall to consumer level GMP/HACCP review
≤ 100cfu/g in five random samples of ground beef derived from positive product
Recall to retail level GMP/HACCP review
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HC Guideline No. 10, March 1999
“Health Canada does not recommend routine testing for this organism as a public health measure as its prevalence is too low for testing to be effective. None-the-less, when Escherichia coliO157:H7 is detected, appropriate public health measures need to be taken. Guidance is provided to the Canadian Food Inspection Agency (CFIA) and other interested stakeholders regarding appropriate public health measures in the situation where a lot of ground beef is implicated due to a positive test for E.coli O157:H7 for ground beef, carcasses or trimmings, or a ground beef equipment surface”.
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Guidance Update - 2012
• Guidance Document on E. coli O157:H7 and E. coli O157:NM in Raw Beef in final draft. Expected release in summer of 2012
• Major Changes:- Strong recommendation for a testing program- Testing for indicator organisms and the processing environment- More specific guidance determining implicated lots
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Walkerton – May 2000
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Summer of 2000
Company recalls meat that may be contaminated with E. coli bacteria (Canadian Press - June 2000)
An Alberta-based meat packer recalled more than 77,000 kilograms of ground beef Friday after a supermarket chain discovered a deadly strain of E. coli bacteria in a batch of meat…….
‘Ground beef recall could be expanded’ (CBC - Nov. 2000)
A recall of hamburger that caused a grocery chain to destroy thousands of kilograms of meat could be expanded…….
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Food Safety Interventions
• Research: Investigation into future interventions at all levels of the food continuum
• Farm: Agricultural sectors develop commodity specific on-farm food safety programs
• Slaughter: Intervention steps introduced during slaughter and carcass dressing procedures (eg. bunging, carcass washing, steam pasteurization)
• Processing: HACCP Programs become mandatory in federal meat facilities (2005)
• Retail/Foodservice: Enhanced regulations, codes and food handler training
• Consumer: Labelling & Education
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Labelling
• In 1997, a national voluntary initiative to provide safe handling and cooking messages was identified as the preferred risk management option in Canada
• Uptake of the voluntary initiative has not been universal
• Messages currently available on products are often incomplete or inconsistent, with guidance being communicated in a variety of formats employing different content, colours, contrasts, fonts, shapes, and positioning on the product packages.
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Strategy – Spring 2012
• Publish detailed safe cooking and handling labelling guidance for consumer packages of raw ground meat and raw ground poultry
- Guidance on Safe Cooking and Handling Labelling for Raw Ground Meat and Raw Ground Poultry
• Industry consultation to obtain detailed information on current practices for safe cooking and handling labelling in the Canadian food industry and feedback on the guidance
- Consultation on Industry Practices for Safe Cooking and Handling Labelling of Raw Ground Meat and Raw Ground Poultry
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Labels
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Consumer Education & Awareness
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Thank You
Bill SlaterRegional Food Policy Liaison OfficerHealth CanadaEdmonton, ABbill.slater@hc-sc.gc.ca780-495-3682