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Collaboration during multi-jurisdictional foodborne outbreak

investigations and response

Canadian Food Inspection Agency (CFIA) Lorraine Haskins, Food Safety Recall Specialist

Office of Food Safety and Recall

Public Health Agency of Canada (PHAC) Popy Dimoulas-Graham, Senior Epidemiologist

Outbreak Management Division, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases (CFEZID)

Tuesday, June 28, 2011 Canadian Institute of Public Health Inspectors (CIPHI) Conference 2011

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Overview

• Emerging Trends• Foodborne Illness Outbreak Response Protocol• Stakeholders and roles• Steps of an outbreak investigation • Salmonella Chester (2010)• Salmonella Carrau (2009)

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Emerging trends in foodborne outbreaks

Public Health Agency of Canada | Agence de la santé publique du Canada 3

• Changes in food production – mega farms and production (centralization), global sourcing– Increase in widely distributed outbreaks

• Changes in eating patterns – chicken, healthier, ready-to-eat– Increase in produce, ready-to-eat related outbreaks

• Increased capacity for detection – PFGE, MLVA– Increase identification of outbreaks that may not cluster in space

• Aging population– More severe outcomes

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Outbreak Truths

• Every outbreak is different• No universally accepted approach to an outbreak• Outbreak response varies with the outbreak, the agencies

involved, available resources, and the surrounding circumstances (e.g., etiologic agent, number of cases, and likely source of exposure, population affected)

• Investigation activities are rarely linear• Communication or implementation of control measures,

occur repeatedly throughout an investigation

 

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Canada’s Foodborne Illness Outbreak Response Protocol (FIORP) 2010:

• Framework to guide multi-jurisdictional collaboration for identification and response

• Defines roles and responsibilities

• Describes guiding principles and operating procedures

• Focus on information exchange, communication and collaboration between agencies

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Multi-jurisdictional Collaboration

• Local and regional public health authorities

• Provincial/territorial governments (health & agriculture)

• Public Health Agency of Canada

• Health Canada (HC)

• Canadian Food Inspection Agency (CFIA)

• International health authorities and food safety agencies

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Current Information Exchange Among Food Safety Partners

OutbreakManagement

Division

U.S. CDC

NML/PulseNetCanada

PulseNet U.S.A

CFIA

Health Canada

Prov/TerrEpidemiologist

Prov/Terr Labs

U.S. FDA

NESP

CFIA LabsIHR

IHR Focal Point

Epi in Country ofInterest

Bites Blog

Pro-MED

U.S. Epi-X

GPHIN

INFOSAN

ECDC

LegandCFIA - Canadian Food Inspection AgencyECDC - European Centre for Disease Prevention and ControlEpi - EpidemiologistGPHIN - Global Public Health Intelligence NetworkIHR - International Health RegulationsINFOSAN - The International Food Safety Authorities Network

NESP - National Enteric Surveillance ProgramNML - National Microbiology LaboratoryProv/ Terr - Province/TerritoryU.S. CDC - U.S. Centers for Disease Control and PreventionU.S. Epi-X - The Epidemic Information ExchangeU.S. FDA - U.S. Food and Drug Administration

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PHAC’s Role in Outbreak Response• Monitor for and respond to enteric disease outbreaks that

involve more than one P/T or country• Lead multi-jurisdictional outbreaks involving more than one

P/T or country• Coordinate epidemiological investigation and information

sharing• Provide consultation, content expertise as requested by P/Ts• Contribute to international foodborne outbreak investigations• Provide epidemiological content expertise to CFIA and Health

Canada• Chair outbreak debriefing sessions• Lead or contribute to the documentation of the outbreaks

through peer review

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CFIA Role in Outbreak Response

• Food safety investigations • Food testing• Recall activities• Regulatory compliance and enforcement

activities• Knowledge of the food production and food

distribution system

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Health Canada Role in Outbreak Response

• Establish policies/guidance and regulations related to food safety

• Set standards• Provide Risk Assessments• Provide advice and information on food safety• Provide applied research and surveillance to support

activities, including Risk Management• Laboratory testing (Reference Services/surge capacity)• Collaborate with government and other partners within

Canada and internationally

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Steps in an Outbreak Investigation

1. Determine existence of an outbreak2. Confirm diagnosis 3. Assemble team 4. Implement immediate control measures5. Develop case definition & find cases6. Analyse time, place, person data7. Generate hypothesis8. Test hypothesis9. Implement prevention & control measures10. Disseminate findings, conduct evaluation

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Determine Existence of an Outbreak

Triggers: Human Illness• Local/regional officials identify outbreak• National or P/T surveillance activities identify an

outbreak (including lab)• International outbreak with the potential to affect

Canada

Triggers: Food product• Agent or pathogen pattern from food is matched

with agent or pathogen pattern in human

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Assemble Team

• Often includes:– Provincial Public Health– Provincial Laboratory– National Microbiology Laboratory, PHAC– CFIA– Health Canada– Outbreak Management Division, PHAC– U.S. CDC and FDA

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Planning and Preparation

• Identify the players and their roles• Standard processes

– Outbreak information management, communication, escalation, recovery and follow-up post outbreak

• Outbreak tools– Case interview forms, databases, communication templates

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Develop case definition & find casesSalmonella Chester (2010)Confirmed case: • Laboratory confirmation of Salmonella Chester with PFGE

pattern ChesXAI.0007/ChesBNI.0002 or ChesXAI.0007/ChesBNI.0003 AND/OR Laboratory confirmation of Salmonella Chester with an epidemiological link to purchase or consumption of head cheese; AND a lab-confirmed date on or after June 1, 2010; AND the individual is a resident of or visitor to Canada.

Probable case: • Laboratory confirmation of Salmonella Chester with PFGE and

exposure information pending; AND a lab-confirmed date on or after June 1, 2010; AND the individual is a resident of or visitor to Canada.

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Analyse data (time, place, person)

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Hypothesis Generation

• Review literature and surveillance data• Person, place, time characteristics of case data

– Investigation techniques based on resources & population affected

• Exposure assessment and comparison with food consumption surveys

• Dynamic process

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Weight of Evidence for Action

• Varies widely• Combination of epidemiological, laboratory and

traceback investigations• Strength relies heavily on quality and specificity of

information and samples collected

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Weight of Epidemiological Evidence

• Strong analytical study not always needed– Descriptive epi plus pathogen identified in food– Descriptive epi plus traceback to unusual vehicle

(e.g., frozen mice fed to corn snakes)

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Salmonella Chester (2010)

Multi-provincial outbreak of S. Chester - Rare serotype of Salmonella in Canada - Between July 5 & Sept 2, 2010, a total of 33

confirmed cases with matching PFGE patterns were reported to PHAC from 4 provinces

- Median age = 75 years; 55% male- 8 (31%) case hospitalized; no deaths reported- Identified headcheese as the source of the

outbreak

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Salmonella Chester (2010) – CFIA

Food Safety Investigation Components • Confirm the product and affected firm

– Packaged product sold at delis– Recall of the head cheese directly associated to the

illnesses• Determine the extent of the problem

– Continue the FSI at the manufacturer level to • Identify other potentially affected head cheese• Identify other potentially affected products

– Process and records review– Recall of additional head cheese and additional

products • Corrective actions identified and implemented

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Salmonella Chester (2010) – Health Canada

• Participated in OICCs• Conducted 7 risk assessments associated with

this event• Provided consultation on sampling• Participated in NEOC• Participated in Thermal Processing Working

Group to evaluate manufacturer’s smoker/cooker validation data

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Salmonella Carrau (2009)

Joint investigation between Canada and U.S.A.- Rare serotype of Salmonella in Canada - Between March 12 & Apr 30, 2009, a total of 35

confirmed cases with matching PFGE patterns were reported to PHAC from 8 provinces

- Median age = 23 years; 57% female- 7 (23%) case hospitalized; 2 deaths- Case-control study conducted

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Salmonella Carrau (2009) – CFIA

Food Safety Investigation Challenges • No label and lot code available • Short shelf-life • Traceback initiated using invoices over large

timeframe• Various Public Health provided some invoices,

grocery receipt and menus.• Collaboration with US FDA for traceback• No single point of origin: more than one possible

supplier and country

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Salmonella Carrau (2009) – Health Canada

• Monitored situation as information became available

• Participated in OICC• No assessments required

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Thank-you. Questions?Lorraine Haskins, Food Safety Recall Specialist, CFIAlorraine.haskins@inspection.gc.ca

Enrico Buenaventura, Section Head, Health Canadaenrico.buenaventura@hc-sc.gc.ca

Popy Dimoulas-Graham, Senior Epidemiologist, PHACpopy.dimoulas-graham@phac-aspc.gc.ca