Independent investigator releases final report on listeriosis outbreak to Canadians

Friday, 24 July, 2009

The final report of Sheila Weatherill, the Independent Investigator of the August 2008 listeriosis outbreak, has been released. The report represents the conclusion of her six-month-long investigation into the outbreak that cost 22 Canadians their lives.

"Ensuring the safety of our food supply is one of government's most important responsibilities," said Sheila Weatherill. "My goal was to provide Canadians with answers about how and why this outbreak occurred and to make recommendations that will help to protect all consumers from future outbreaks or optimise the response if they do arise."

Mrs Sheila Weatherill was appointed by the Prime Minister of Canada in January 2009. In the process of her investigation, more than 100 key individuals were interviewed or met, including affected family members, representatives of industry and labour, and officials from all levels of government. The investigation received more than 400 comments from Canadians through the investigation's website and reviewed millions of pages of documentation. The investigation also received advice from a group of experts made up of respected Canadian and US food safety and public health advisors.

"I learned that reviewing the outbreak in hindsight allowed me to see the sequence of events that led to the outbreak and to identify steps that could have been taken," Weatherill commented. "I heard, repeatedly, that if people had only known or recognised then what they know now, these events may have evolved differently. Despite these best efforts and insights, 22 lives were lost," she added.

The Investigation identified four broad categories where improvements need to be made. There must be:

  • more focus on food safety among senior officials in both the public and private sectors;
  • better preparedness for dealing with a serious foodborne illness with more advance planning for an emergency response;
  • a greater sense of urgency if another foodborne emergency occurs;
  • clearer communications with the Canadian public about listeriosis and other foodborne illnesses, especially at risk populations and health professionals.

Key conclusions from the Investigation include:

  • Almost 80% of those who developed listeriosis lived in a long-term care home or were admitted to a hospital that had served contaminated deli meats from large packages produced specifically for institutions;
  • Evidence of food contact surface contamination on ready-to-eat meat production lines was available months before the outbreak. These trends were not being monitored to identify a recurring problem. There was no legal obligation to report this contamination, and there was no requirement for government inspectors to request this information;
  • There existed a lack of understanding about intergovernmental protocols to deal with such emergencies, creating confusion about who should do what and when;
  • Policies and directives were sometimes vague, therefore open to different interpretation, and thus creating opportunity for problems;
  • Most organisations involved in the response to the outbreak had limited pre-planned surge or redundant capacity. There were not enough workers to handle such a foodborne emergency and summer replacement workers dealing with it did not all understand their roles;
  • The majority of Canadians were unaware which segments of the population were at greater risk of becoming ill if exposed to Listeria monocytogenes, and what foods these vulnerable groups should avoid. Simple, clear information about these risks and how to protect themselves was not always effectively communicated to people at increased risk for listeriosis, health professionals and the general public.

"Canada's food safety system is made up of a complex set of safety laws and regulations administered by a network of federal, provincial and local agencies," Weatherill said. "My report recommends that both regulators and business place safeguarding consumers at the centre of their consciousness and collective actions."

After in-depth analysis and advice from food safety and public health experts the Independent Investigator made 57 recommendations for improvements to Canada's food safety system. The recommendations address:

  •  the safety culture of food processing companies;
  • design of food processing equipment;
  • government rules and requirements for food safety;
  •  the need for food service providers to adopt food safety practices aimed at vulnerable populations; and
  • government's capacity to manage national foodborne illness emergencies.

"Some of our country's most vulnerable people lost their lives to this tragedy," concluded Weatherill. "It is my hope that timely action will be taken to respond to this report in order to prevent a similar tragedy from ever occurring in this country again."

Weatherill is also recommending to the Minister of Agriculture and Agri-Food to report back to Canadians within two years on the status of the implementation of her report.

The work of the Investigation has been complemented by the important work of the House of Commons Agriculture Subcommittee on Food Safety, which has also examined many aspects of this critical matter.

The full report is available.

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