Public Health Agency of Canada (PHAC) 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

Overview Emerging Trends Foodborne Illness Outbreak Response Protocol Stakeholders and roles Steps of an outbreak investigation Salmonella Chester (2010) Salmonella Carrau (2009) Especially true following high profile outbreaks like the listeriosis outbreak in 2008 and with the advent of widespread internet use and social media. Rapid pace of communications and information demands.

Emerging trends in foodborne outbreaks 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 I represent… Primarily foodborne but enteric diseases – animal contact such as petting zoos, waterborne outbreaks, person to person transmission at a daycare – more often than food, restricted to one jurisdiction so not involved. Foodborne, frequently multi-jurisdictional – involved in 50 outbreak issues each year with potential to become multi-jurisdictional Before development of pathogen-specific surveillance, foodborne disease outbreaks were typically recognized because of the occurrence of large numbers of illnesses among persons with a known common exposure. The development of pathogen-specific surveillance through public health laboratories has allowed the detection of widely dispersed outbreaks caused by commercially distributed food products. Outbreaks identified through pathogen-specific surveillance are initially recognized as clusters of cases defined by subtype characteristics. Distribution of these cases by time, space, and personal characteristics provides important clues about whether the cases are likely to represent an outbreak from a common source of exposure. However, only a systematic investigation of the cluster can confirm whether it actually is an outbreak and, if so, whether it is a foodborne disease outbreak. Public Health Agency of Canada | Agence de la santé publique du Canada 3

Globalization – wide commercial distribution, air travel, increased international trade Geographically dispersed cases, introduction of new pathogens Examining the ingredients in a taco paints a picture of the globalization of our food production network group of archtecture students that deconstructed a taco to demonstrate the effect of globalization on the food we eat goal was to map the ‘tacoshed’ According to the class findings, within a single taco, the ingredients had traveled a total of 64,000 miles, or just over two and a half times the circumference of the earth. http://www.good.is/post/your-taco-deconstructed/ The changing picture of how we get our food impacts the nature of outbreaks Multi-jurisdictional collaboration!

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  

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 Timely and clear communication and coordination between partners is one of the most critical challenges in outbreak investigation. Protocol to guide very helpful – worked out in advance as part of planning and preparation. Bringing multiple agencies with different mandates together can be challenging, and it’s important to bring responsible parties together to mutually agree on a framework, and Canada has done just that... The principal framework document which guides multi-jurisdictional collaboration in response to food-borne illness outbreaks in Canada is the Foodborne Illness Outbreak Response Protocol (FIORP) Developed by the Public Health Agency of Canada (PHAC), Health Canada (HC), and the Canadian Food Inspection Agency (CFIA), in consultation with provincial/territorial (P/T) stakeholders, to enhance the collaboration and overall effectiveness of response during multi-jurisdictional food-borne illness outbreaks Defines guiding principles, roles and responsibilities and operating procedures for outbreak investigation that cross provincial jurisdictions Some provinces (eg. Alberta, BC, Ontario, MB, NS also have specific protocol guidelines for their provinces as well) Full document can be found on PHAC website Remember, JUST A FRAMEWORK... No two outbreaks are exactly the same The structure and leadership of the outbreak team will vary depending on the nature of the outbreak, how it was detected, characteristics of the pathogen and the distribution of cases eg. detected at the local level, clustered mainly within a geographic region, vs. widely dispersed outbreak detected via laboratory diagnostics Responsibilities for responding to food-borne illness outbreaks may be shared between federal/provincial/territorial (F/P/T) and local/regional jurisdictions.  The response to such situations involves collaboration and cooperation among all those involved. 

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 Bringing multiple agencies with different mandates together can be challenging, and it’s important to bring responsible parties together to mutually agree on a framework, and Canada has done just that... The principal framework document which guides multi-jurisdictional collaboration in response to food-borne illness outbreaks in Canada is the Foodborne Illness Outbreak Response Protocol (FIORP) Developed by the Public Health Agency of Canada (PHAC), Health Canada (HC), and the Canadian Food Inspection Agency (CFIA), in consultation with provincial/territorial (P/T) stakeholders, to enhance the collaboration and overall effectiveness of response during multi-jurisdictional food-borne illness outbreaks Defines guiding principles, roles and responsibilities and operating procedures for outbreak investigation that cross provincial jurisdictions Some provinces (eg. Alberta, BC, Ontario, MB, NS also have specific protocol guidelines for their provinces as well) Full document can be found on PHAC website Remember, JUST A FRAMEWORK... No two outbreaks are exactly the same The structure and leadership of the outbreak team will vary depending on the nature of the outbreak, how it was detected, characteristics of the pathogen and the distribution of cases eg. detected at the local level, clustered mainly within a geographic region, vs. widely dispersed outbreak detected via laboratory diagnostics Responsibilities for responding to food-borne illness outbreaks may be shared between federal/provincial/territorial (F/P/T) and local/regional jurisdictions.  The response to such situations involves collaboration and cooperation among all those involved. 

Current Information Exchange Among Food Safety Partners Partners and flow of information. Red = primary points of contact. Blue = partners from whom we receive information through our primary partners. Grey = sources of information that we receive but for the most part do not exchange information with Information exchange is not linear but varied; ongoing; demonstrates how information about a potential cluster or outbreak can originate from many sources.

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 9

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 CFIA delivers all federal inspection and enforcement services related to food under the authority of 13 federal acts that address all stages of the food continuum. Not only does CFIA inspect foods, but also the seed, livestock feed, fertilizers, plants and animals on which a safe food supply depends. CFIA’s contribution to the investigation and control of foodborne illness outbreaks includes its food safety investigation, testing and recall activities, as well as its regulatory compliance and enforcement activities. Food Safety investigation - (for foods imported or shipped interprovincially, or manufactured in an establishment under CFIA’s jurisdiction) Food testing – routine monitoring programs and samples from establishment under investigation, in distribution facilities. Recall – health hazard alert issued, communications regarding recalls, recall effectiveness checks in collaboration with public health, detain. Regulatory compliance and enforcement activities 10

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 11

Steps in an Outbreak Investigation Determine existence of an outbreak Confirm diagnosis Assemble team Implement immediate control measures Develop case definition & find cases Analyse time, place, person data Generate hypothesis Test hypothesis Implement prevention & control measures Disseminate findings, conduct evaluation ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence

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 NESP Administered by NML and CFEZID Weekly, aggregate, laboratory-based Purpose Monitor trends over time and geography Detect increases across jurisdictions Pathogens (under review) Salmonella, Campylobacter, Shigella, Vibrio, E. coli, Yersinia, Giardia, Cryptosporidium, Entamoeba, Rotavirus, Norovirus ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 13

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 ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 14

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

Develop case definition & find cases Salmonella 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. ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 16

Analyse data (time, place, person) ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 17

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 Hypothesis generation should begin early in an outbreak investigation narrow the focus of the investigation and use time and resources most effectively Key steps in hypothesis generation include the following: Reviewing previously identified risk factors and exposures for the disease; Examining the descriptive epidemiology of cases to identify person, place, or time characteristics that might suggest particularly likely exposures; and Interviewing in detail the affected persons or a sample of affected persons to identify unusual exposures or commonalities among cases (5.1.2.4). Cluster investigation techniques Should be based on resources and populations Ex. dynamic cluster investigation initial cases in a recognized cluster are interviewed with a detailed exposure history questionnaire. As new suspicious exposures are suggested during the interviews (i.e., are reported among 5-10 cases), initial cases are systematically re- interviewed to uniformly assess their exposure and the suspicious exposure is added to the interview of subsequently identified cases. *other examples For agencies that routinely interview ALL cases with a detailed exposure questionnaire, dynamic cluster investigation can be initiated as soon as a cluster is recognized. Such an approach results in improved recall because cases are more likely to remember exposures when specifically questioned about them. For agencies that do not have sufficient resources to conduct detailed exposure history interviews for every case, a two-step interviewing process may be the best alternative approach. All cases are interviewed to collect information about a limited set of “high-risk” exposures specific to the pathogen. When a cluster becomes apparent, all cases in the cluster are then interviewed using a detailed exposure questionnaire following the “dynamic cluster investigation” approach (5.2.4.1.2.2). For agencies that do not have sufficient resources to conduct detailed interviews with all cases in a cluster, hypothesis- generating interviews can be undertaken with a subset of cases after a cluster becomes obvious. Exposures reported by a substantial proportion of these cases can then be studied

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 Scientific evidence needed to proceed with an action to implement control measures as quickly as possible and prevent further illnesses varies widely, and is usually based on a combination of different factors.

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) Is it plausible that a given food item is the vehicle of infection? Is a given food item consistently reported across different populations? Is the temporal and/or spatial clustering of cases consistent with the availability/distribution of a particular food product? Does the information provided indicate a single specific food product as the vehicle of infection? How strong is the statistical association between a given food item and the foodborne illness? Do strain typing results support the epidemiology? Have alternative hypotheses been ruled out?

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 PHAC to discuss their role during outbreak 21

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 ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 22

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 ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 23

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 PHAC to discuss their role during outbreak 24

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 ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 25

Salmonella Carrau (2009) – Health Canada Monitored situation as information became available Participated in OICC No assessments required ‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines Speed and accuracy Flexible and innovative, yet systematic Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten Skipping to epi – hypothesis generation, weight of evidence 26

Thank-you. Questions? Lorraine Haskins, Food Safety Recall Specialist, CFIA lorraine.haskins@inspection.gc.ca Enrico Buenaventura, Section Head, Health Canada enrico.buenaventura@hc-sc.gc.ca Popy Dimoulas-Graham, Senior Epidemiologist, PHAC popy.dimoulas-graham@phac-aspc.gc.ca