Action on Weatherill Report Recommendations to Strengthen the Food Safety System: Final Report to Canadians

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Listeriosis is a rare but serious foodborne illness. It primarily affects older people, pregnant women and immuno-compromised adults, all of whom are more vulnerable to foodborne illness than the general population. In the summer of 2008, the presence of Listeria monocytogenes in ready-to-eat (RTE) meat caused a listeriosis outbreak, which resulted in the deaths of 23 Canadians.

Immediately after the outbreak, both industry and government began to examine how they could work to prevent such an outbreak in the future, and how to minimize harm when food contamination occurs.

At the federal level, each of the organizations responsible for food safety and foodborne illness events—the Canadian Food Inspection Agency (CFIA), Health Canada and the Public Health Agency of Canada (PHAC)—implemented an action plan to strengthen its response to outbreaks of foodborne illness.

Because of the serious nature of the listeriosis outbreak, the Government of Canada also asked Ms. Sheila Weatherill to lead an independent investigation into the circumstances of the outbreak and to make recommendations to strengthen the food safety system.

Food Safety Responsibilities

The responsibility for food safety and foodborne illness outbreaks is shared by federal, provincial and territorial governments, industry and consumers:

The food industry is responsible for the production of safe food in compliance with government standards.

Provincial, territorial and local governments enact and enforce food safety laws that apply to food produced and sold within the borders of each jurisdiction and that complement federal legislation. They engage in activities such as inspection, public health and food safety surveillance, and education and training programs for food handlers.

Consumers and food service providers are responsible for safe food handling and preparation in order to protect themselves and others from foodborne illness.

Health Canada is responsible for establishing food safety policy and standards governing the safety and nutritional quality of all food sold in Canada, as well as for assessing the effectiveness of the Canadian Food Inspection Agency's (CFIA) food safety activities. Health Canada engages in research and health risk and benefit assessments, as well as pre-market assessments of food additives, novel foods, new technologies and specific food products, and communicates to the public on food safety issues. It also plays a key role in support of CFIA food-safety-incidents management by providing timely health risk assessments.

The Canadian Food Inspection Agency is responsible for enforcing policies and standards set by Health Canada for food sold in Canada, for the delivery of federal food inspection programs, and for verifying industry compliance with food safety regulations. The Agency also initiates food recalls in collaboration with industry and investigates foods responsible for foodborne illness outbreaks.

The Public Health Agency of Canada engages in public health surveillance. It also leads the coordination with provincial and territorial public health officials of foodborne illness outbreak investigations and responses whenever more than one province, territory or country is involved.

The Weatherill Report

Cover - Report of the Independent Investigator into the 2008 Listeriosis Outbreak

In July 2009, the Report of the Independent Investigator into the 2008 Listeriosis Outbreak (the Weatherill Report) was submitted to the Government and publicly released. The Report describes the Canadian food safety system and the responsibilities of industry and government, examines what went wrong, and puts forward a set of recommendations for strengthening the food safety system and for minimizing the risk of a similar outbreak in the future. The Report notes that most of its recommendations are for "swift and significant action in key areas" and encourages the Government to look for "longer-term solutions to the remaining challenges"Footnote 2.

The Report relates the chain of events that led to the recall of meat products from a meat processing plant in central Ontario, and assesses how well federal organizations and their food safety partners responded to those events.

The Independent Investigator notes that Canada's food safety approach is considered among the best in the world, and emphasizes that Canadians can have confidence in the food safety system. However, she also makes clear that her investigation found circumstances that need to be addressed to better protect Canadians. These are presented in four broad categories:

1. the focus on food safety among senior management in both private and public domains

At the Ontario plant, evidence of recurring contamination was not being monitored through trend analysis. Information about Listeria contamination did not always reach the uppermost levels of management at the plant or in government. There were cases of inadequate decision making, and some policies and directives were vague and left open to interpretation. Government approval processes for new food additives and techniques that could contribute to food safety were not prioritized.

2. the state of readiness of various governments

The Investigator perceived a lack of advance planning and preparation, so that governments were not immediately prepared for a multi-jurisdictional response as the outbreak developed. As well, there was a general lack of understanding among government partners of the existing intergovernmental protocol for handling foodborne illness outbreaks, which led to confusion about the division of responsibilities among the various authorities.The lack of emergency surge capacity, inadequate training of temporary replacement staff and insufficient training of food inspectors in new inspection procedures were among the factors cited.

3. the sense of urgency at the commencement of the outbreak

Over one particular critical weekend, both government staff and information were unavailable, causing a delay in decision making. There was a lack of consensus as to the appropriate time to warn the public about potentially harmful foods. The activation of emergency operations centres was late in coming, and direction from authorities at the national level was noticeably lacking.

4. national communications with the public

Evidence gathered from polling, as well as from personal anecdotes, showed that communications about the outbreak did not provide the information Canadians needed. "There was near-unanimous agreement," the Investigator points out, "that Canadians were confused following news of the food recalls"Footnote 3. It was concluded that Canadians want clear, simple information on what is happening during an outbreak and on how to protect themselves from foodborne illness.

The Independent Investigator acknowledges the complexity of the undertaking and the intensity of the pressure to deal with the outbreak while responding to public concerns. She points out that food safety risks have become greater with the advent of large-scale farming and food production, and global food markets. She also notes that listeriosis is a difficult infection to detect, resembling the flu at onset and requiring time-consuming laboratory testing to analyze and identify.

The Investigator also acknowledges that a great deal of hard work and dedication was exerted on finding the source of the illness, making the contamination link from humans back to the foods, removing the products from the market and managing communication of the event to the public. In addition, she points out that by 2009, actions were already under way to correct problems that were identified immediately after the outbreak.

Nevertheless, the Investigator calls for further action in specific areas: the culture of food processing companies; the Government's rules and requirements for food safety; the Government's capacity to manage multi-jurisdictional foodborne outbreaks; and the relationships among, and defined responsibilities of, all levels of government. She further suggests that, given the status of foodborne illness as the largest class of emerging infectious disease in the country, the Canadian government ought to emphatically commit to the safety of food as one of its top priorities.

Finally, the Investigator notes that, while they are not the focus of the review, issues of legislation and regulation, as well as governance, should be acted upon in order to modernize and reform the food safety system.

The Government Responds

In September 2009, the Government announced its agreement to act on all of the recommendations of the Weatherill Report. The Clerk of the Privy Council asked the Deputy Minister of Agriculture and Agri-Food Canada (AAFC) to take on an oversight role in the coordination of actions by CFIA, Health Canada and PHAC in response to the recommendations of the Weatherill Report. The Special Committee of Deputy Heads (SCDH) was formed to ensure that all food safety partners are better positioned to share information and provide a more cohesive and forward-looking approach to food safety. The SCDH has overseen action taken toward the implementation of all 57 recommendations and has kept Canadians informed on progress through a series of three interim reports posted on the Food Safety Portal.

This final report describes the action taken since September 2009 with specific reference to three priority areas—reducing food safety risks, enhancing surveillance and early detection, and improving emergency response.

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