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Management Response

September 2011

Contents

1 Introduction

1.1 Evaluation scope, objectives and issues explored

1.1.1 Background and scope

The Weatherill Report was released in July 2009, outlining the events that led to the 2008 listeriosis outbreak and examining what occurred. Among the weaknesses identified in the report were inadequacies in the inter-departmental and inter-jurisdictional interfaces related to food safety investigations and emergency response.

Since the publication of that report, the Canadian Food Inspection Agency (CFIA), Health Canada (HC) and the Public Health Agency of Canada (PHAC) have implemented a number of measures to improve and strengthen their inter-departmental interfaces. These include:

  • Updating the Foodborne Illness Outbreak Response Protocol (FIORP). This protocol was in place at the time of the listeriosis outbreak, but according to the Weatherill Report it was not used consistently. The revised Protocol is reportedly now ready for use and outlines the role of each federal department and agency, as well as the roles of the provinces and territories. It also lays out provisions regarding information sharing and communications.
  • Development (with PHAC) of the Foodborne Illness Emergency Response Plan.
  • Implementation (by the CFIA) of the Incident Command Structure.
  • Development of guidelines on the weight of evidence needed to take action.
  • Formation of the Agri-Subcommittee on Food Safety.
  • Formation of the Network of Networks Federal Committee (involving PHAC, HC, and the CFIA) in an effort to improve exchange of food-related laboratory data, expertise and enhance lab capacity.
  • Formation of a Committee of Department Heads to improve coordination.
  • Development of new internal governance mechanisms (for HC, PHAC, and the CFIA).

The extent to which they (and other measures) are likely to work - and work together - to improve inter-departmental interfaces in the event of a food safety incident was yet to be determined as of May 2011. Understanding the effects of these measures was the main purpose of this study, which will form part of the government's report, due in the Fall of 2011, on the progress that has been made in responding to the recommendations of the Weatherill Report.

1.2 Objectives

The objective of this study was "…to assess the design and effectiveness of the inter-departmental and inter-jurisdictional interfaces during a food safety incident." It focused on the measures that have been implemented, primarily by the CFIA, during the two-year period 2009-10 and 2010-11.

1.3 Issues

The evaluation issues and questions that were addressed in the study are focussed on design and efficiency (Processes and Procedures, Governance Structures), and success and effectiveness (Immediate and Intermediate Outcomes). Eight questions were developed to address these issues (see Appendix A). These questions were explored through a combination of document and file review, interviews (strategic and stakeholder) and case studies. The case studies describe key incidents that have taken place during the study period that can be used as proxies for food safety crises, or aspects of food safety crises.

The table in Appendix A contains the evaluation matrix, which summarizes the indicators, methodologies that were applied and data sources, for each of the evaluation questions identified.

1.4 Governance

The Interdepartmental Evaluation Advisory Committee is the authority on this report. The composition of that Advisory Committee is located in Appendix B.

2 Methodologies

This study consisted of multiple lines of inquiry to address the eight evaluation questions: documentation review, strategic and stakeholder interviews, and case studies.

2.1 Documentation review

A review of key documentation related to the 2008 listeriosis outbreak was conducted. The specific key documentation reviewed is listed in Appendix C.

2.2 Strategic and stakeholder interviews

The strategic interviews were comprised of four individuals with specific knowledge about the 2008 outbreak or the Weatherill recommendations. The individuals identified for strategic interviews were on the basis of selected based on recommendations by each of the involved departments and agencies (the CFIA, HC, and PHAC).

The stakeholder interviews were comprised of 20 individuals, representing the CFIA, HC, and PHAC, with working level knowledge about processes and procedures related to emergency management of foodborne illness outbreak events. These individuals were selected for interviews based on the fact that they represent three key branches – Operations, Public Affairs, and Policy and Programs – and that they work in the NCR as well as in other areas of the country including the provincial level of government. The interview guides are located in appendices C and D.

2.3 Case studies

Case studies were developed on foodborne illness incidents strating in 2009. The case studies provided specific examples of efficiencies and successes of the management of such incidents, and explored the extent to which actions in response to the Weatherill recommendations may have had an impact on the ability to efficiently and effectively deal with such incidents.

Case studies consisted of a document review and interviews with nine key individuals involved in the incident. All have been reviewed and validated by interviewed parties.

2.4 Methodological limitations

There were few limitations to the methodologies implemented for this study. Regarding the documentation review, there is a limitation with respect to the materials reviewed. There is always the possibility that some documents may not have been reviewed, because there was a lack of awareness of their existence. It is unlikely that critical information was not reviewed in the conduct of this evaluation.

2.5 Restrictions and limitations

The work undertaken was limited to the objectives, scope and evaluation questions presented in Section 1 of this report. Further, the work was limited to, and observations and recommendations are based on, the work plan outlined in the Methodology Report. It is also important to highlight that in an engagement such as this where key informant interviews were a significant source of the information gathered for analysis, that the evaluation relied on the information from and representations by the CFIA, PHAC, HC and other relevant stakeholders engaged throughout the study for completeness and accuracy of information and insights provided.

3 Key Findings

This section of the report presents key findings in relation to each of the eight evaluation questions which defined the scope of the study. Each question is addressed individually including an overall response to the question supported by the key findings, real or perceived gaps, and options or recommendations for future consideration.

Overall, the data gathered through the course of this review suggests that the inter-departmental, inter-jurisdictional ability to manage and respond to foodborne illness outbreaks has been significantly strengthened since the release of the Weatherill Report in 2009. Based on the data gathered and assessed, it is apparent that the key stakeholders, i.e., the CFIA, HC, PHAC, and the provinces and territories, have invested time and attention to enhancing existing documentation and governance structures. Additionally, investments have been made in developing and implementing new documentation and governance structures, as well as in clarifying roles and responsibilities with respect to foodborne illness outbreak coordination, communication, response and management.

Despite these changes, it has become apparent that opportunities for continued focus and improvement exist. For example, provinces and territories (P/T) are in need of additional guidance, so that increased process consistency can be achieved when responding to, and managing, multi-jurisdictional foodborne illness outbreaks. Improvements with respect to documenting roles and responsibilities in single jurisdiction foodborne illness incidents may assist in this area. Moreover, some improvements can be made with regard to interactions between P/T and federal laboratories, as well as to P/T ability to adapt new methods of testing introduced at the federal level. Finally, there is still some room to improve direct coordination between PHAC and the CFIA in specific areas. To that end, it appears that some additional improvements can and should be made, particularly with respect to the governance surrounding the interactions of P/T and federal labs.

The balance of this section of the report contains a summary of key findings against each of the evaluation questions. The summary findings are kept brief, with Appendix F containing extensive details that further elaborate on the findings presented in this section. All the findings are based on the information gathered through the three lines of inquiry (i.e., documentation review, interviews and case study preparation).

3.1 Design and efficiency

3.1.1 Are the processes and procedures clearly documented and executed?

A variety of documents have been prepared and their content implemented by the CFIA, PHAC and HC to define, communicate and guide the protocols that govern the roles, responsibilities, efforts, actions and inter-dependencies between and among these federal entities, as well as P/Ts in the event of a foodborne illness outbreak.

There are currently two types of documents:

  1. departmental/agency-centric documentation, which defines the internal protocols, processes and procedures of each specific department and agency; and
  2. overarching documentation defining protocols, processes and procedures involving more than one department or agency that are employed when a multi-jurisdictional outbreak occurs.

Interview and case study data suggests that protocols, processes and procedures are executed when necessary. However, numerous federal interviewees noted that P/Ts are in need of additional guidance so that increased process consistency can be achieved responding to and managing multi-jurisdictional foodborne illness outbreaks.

Regarding communications protocols, the Food Safety Communications Protocol (an annex to the FIORP) is the key document guiding communications during foodborne illness outbreaks, but it was not clear when that protocol is explicitly applied over department-specific communications protocols.

Additionally, it was reported that current documentation has undergone marked improvement over the past two years and will continue to evolve through adherence, lessons learned and overall continuous improvement. Based on interview data, it appears that the degree of commitment for this on the part of those interviewed from the CFIA, PHAC, HC and provinces is high.

As a final note, improvements may be required to support some consistency at the P/T and local health unit levels. Differences in the way doctors approach diagnosing and treating illness, coupled with the challenge in getting P/Ts to fund surveillance activities, can result in absent or late reporting of a foodborne illness being reported late, or not at all.

Conclusions:
Emergency management response to foodborne illness outbreak process and procedures are documented and executed, for the most part. Evidence suggests that P/T partners are in need of further guidance on certain processes and procedures.

3.1.2 Are there appropriate governance structures in place and how effective are they?

It appears that appropriate governance structures are in place today to provide oversight to the CFIA, PHAC and HC, in connection with foodborne illness outbreaks.

Further, the data collected through interviews with the CFIA, PHAC, HC, and provincial representatives suggests an overall belief that the structures in place are working effectively and that marked improvements have been made in this area over the past two years.

As an example, organizational structure changes have been made, and new committees and systems have been designed and implemented within each of the three federal organizations, as well as across the three federal organizations. In some cases, these committees and systems have crossed into provincial boundaries, thus permitting enhanced cross-jurisdictional governance over foodborne illness outbreaks.

It appears that some additional improvements can and should be made, particularly with respect to the governance surrounding the interactions of P/T public health labs and federal labs, such as those operated by CFIA. In particular, there is the inability of the CFIA to share certain types of data with P/T. Due to confidentiality concerns, there may be an issue with sharing food distribution data. The Office of Food Safety Recall (OFSR) within the CFIA is reportedly working to resolve this information-sharing issue, and it has reportedly improved.

Conclusions:
Appropriate governance structures are in place and are fulfilling oversight responsibilities. Additional areas for improvement exist in the area of information-sharing between P/T and federal labs.

3.1.3 Are the roles and responsibilities clearly documented and understood?

Generally, roles and responsibilities are clearly documented and understood by partners in the event of multi-jurisdictional foodborne illness outbreaks in which the FIORP is activated and PHAC is the lead. The roles and responsibilities associated with the lab network continue to evolve nationally. The current version of the FIORP does not discuss roles and responsibilities of these labs. In 2011, the Standard Operating Procedure (SOP) for Directing Food Samples Collected during Epidemiological/Public Health/Food Safety Investigations to the Federal Laboratory Network was developed. This SOP provides a step-by-step process for testing food samples, and lays out roles and responsibilities, thereby complementing the FIORP.

Improvements may be necessary with regard to the degree of clarity and understanding of roles and responsibilities in single-jurisdiction foodborne illness incidents, as currently there is only a moderate level of understanding. This may, in part, be the result of such factors as existing memoranda of understanding (MOUs) between the CFIA and P/Ts, or PHAC and P/Ts not being as clear and concise as the FIORP, or because of less communication and awareness-building with respect to roles and responsibilities at the P/T level, and at the CFIA or PHAC Area levels.

Another area where improvements may be needed is with some of the details provided in the FIORP. For example, the Protocol does not clearly indicate the composition of the Outbreak Investigation Coordinating Committee (OICC) and whether there is a need or means to ensure continuity or knowledge transfer. Such details can be clarified in the next revision of the Protocol.

The Japan Disaster case study (March 11, 2011 earthquake, tsunami and nuclear meltdown) noted that not all staff working on the Japan incident were clear on their respective roles and responsibilities, particularly at the outset of the response. This may be in part because not all staff had received training or participated in table-top exercises recently led by PHAC, which were reportedly very effective in clarifying and enhancing the degree of understanding surrounding foodborne illness outbreaks. The table-top exercises each consisted of running P/T partners through a mock outbreak scenario, which allowed participants to practice using the various components of FIORP in a multi-jurisdictional outbreak situation.

Another contributing factor was that this incident was unprecedented (e.g., it was an international emergency with potential food hazard implications requiring the collaboration of a large number of federal partners who did not routinely work together), and required time and attention to determine the best approach.

Two additional key messages emerged through stakeholder interviews:

  1. Numerous interviewed stakeholders noted the critical importance of continuous communication, training and awareness-building to help ensure clarity and understanding of various roles and responsibilities.
  2. Numerous interviewees also noted that the "human network" within, between and among federal and P/T stakeholders is strong and contributes to the clarity of roles and responsibilities. It is important to balance this by way of ensuring that clearly documented, communicated, understood and adhered-to roles and responsibilities exist.

Conclusions:
Roles and responsibilities are documented and well-understood. An area for improvement relates to the roles of various partners when the FIORP is not applied. In situations when F/P/T MOUs are applied, more clarity is required. The SOP for Directing Food Samples Collected during Epidemiological/Public Health/Food Safety Investigations to the Federal Laboratory Network provides a step-by-step process for testing food samples, and lays out roles and responsibilities, thereby complementing the FIORP.

3.1.4 How effective is the decision-making process?

The decision-making process employed during the emergency management of foodborne illness outbreaks is effective. A strong piece of evidence to support this is the completion of a hot wash following each incident, in which a formal debrief is conducted within the program area, and a subsequent Management Response Action Plan (MRAP) is completed to identify lessons learned. Additionally, the CFIA has assigned responsibility for coordinating the review of lessons learned reports, which may include hot washes, to the Office of Emergency Management. This was primarily in response to an Office of the Auditor General Report entitled, Animal Diseases which examined emergency responses in the context of animal health and noted some deficiencies in the follow-up to the program-level hot wash exercises.

Some interviewees acknowledged that sometimes decisions have to be made with minimal information, but with a potentially high level of risk. Some also offered the opinion that the timeliness around some decisions might be improved. Specifically, some interviewees stated that they believe the time to decide when and what to communicate to the public during an outbreak is lengthy at times.

This may be a result of the nature of publicly communicating foodborne illness outbreak information, or it may relate to the investigation and recall process, in which the accuracy of the messaging is critical to avoid harm to consumers and to the companies and industries involved. For example, different incidents require different types of responses. Consequently, some incidents require longer timelines before public communication can be made. For example, before communications can be drafted and transmitted to the public, communications officials must wait on decisions by emergency management officials, who in turn must wait on certain evidence before decisions can be made.

Once decisions are made, the communication must happen quickly, but coordination is required throughout this process. The reality is that responding to potential public emergencies requires a certain level of caution. This is a policy matter which may warrant regular discussion by the three federal departments and agencies with input and support from P/T partners during its periodic reviews of these processes.

Conclusions:
Decision-making during emergency management of foodborne illness outbreak is effective. Hot wash activities and MRAP development helps to inform future decisions, based on lessons learned. The reality of work in the area of public emergency is naturally cautious given the ramifications of decisions and may warrant regular review between federal partners.

3.2 Success and effectiveness

3.2.1 Is there an identified Government of Canada lead to coordinate federal response efforts?

It is clear that PHAC is identified as the GoC lead to coordinate federal response efforts. This is evidenced in the FIORP.

In addition to this being clearly documented, all interviewed stakeholders, at the federal and provincial levels, correctly cited PHAC as lead to coordinate federal response efforts in foodborne illness outbreaks when an OICC is called. CFIA is always the clear lead for federal food investigations and recall. Finally, in other matters involving food safety, which may fall into the area of public safety, Public Safety Canada would lead (as in the Japan Disaster).

Conclusions:
PHAC is the GoC lead to coordinate federal response efforts, and this is well understood by partners.

3.2.2 Has the F/P/T management of foodborne emergency response improved?

The federal, provincial and territorial (F/P/T) emergency management of foodborne illness outbreaks has improved. This has primarily been a result of improved documentation and increased knowledge, awareness and understanding of documented protocols, roles and responsibilities.

The FIORP exercises yielded numerous benefits to assist in the management of foodborne emergency response. These included:

  • Improved clarity around when to post Public Health Alerts (PHA);
  • Improved clarity around certain classifications under Pulse Field Gel Electrophoresis (PFGE);
  • Improved clarity around the circumstances in which PHAC would lead the OICC, compared to a P/T partner;
  • Improved understanding about when and how to inform the public of incidents or events; and
  • Improved understanding of the recall process, weight of evidence and health risk assessments.

Conclusions:
Emergency management of foodborne illness outbreak has improved. Documentation, including documented results of the FIORP exercises, has been effective in improving clarity and understanding around various key issues.

3.2.3 Is there improved coordination of F/P/T emergency response to multi-jurisdictional food-borne illness outbreaks?

F/P/T coordination during emergency management of foodborne illness outbreaks has improved. This is primarily evidenced by successful examples of information-sharing amongst F/P/T partners in real emergency management incidents, including the response during the Japan Disaster, as well as a result of 13 table-top exercises which were effective and useful.

Despite these improvements to coordination, interviewees noted that additional improvements can and should continue to be made to further enhance the efficiency and effectiveness of coordination. For example, provincial interviewees believe that there is too much planning emphasis on the meat sector, and too little on others, such as dairy and fish. From the P/T perspective, a foodborne illness outbreak involving a product other than meat may result in some uncertainty about procedures. Also, several federal interviewees believe that the P/Ts are not as far advanced in their understanding of procedures during foodborne illness outbreaks. One example was provided in which a provincial ministry of health phoned the President of the CFIA directly during an incident, when coordination should have gone through the CFIA provincial area representative.

Another area to be considered for improvement is the coordination between PHAC and the CFIA, particularly in communication during foodborne illness outbreak. During one outbreak situation, the CFIA announced a recall, and PHAC subsequently released an alert of the recall including a warning to cook the product to an identified safe temperature before consumption. This message reportedly created confusion in the media and amongst P/Ts. Although the issue may be confined to this incident, more coordinated communication between the two agencies may be required to avert any future problems.

Conclusions:
F/P/T coordination during emergency management of foodborne illness outbreak has improved. Areas for improvement still exist; related to coordination between PHAC and CFIA, as well as with improved understanding about certain requirements on the part of P/Ts.

3.2.4 Is there strengthened intra- and inter-jurisdictional ability to manage and respond to foodborne illness?

The intra- and inter-jurisdictional ability to manage and respond to foodborne illness has strengthened since the implementation of Weatherill recommendations.

This is supported by reports of strengthened relationships, on a personal level, among key individuals as well as strengthened inter-departmental relationships previously described as having been fostered. There was a report that people are now engaged vertically within departments and jurisdictions, but horizontally across departments and jurisdictions as well. In addition, reports of successfully managed emergencies, which required strong inter-jurisdictional response (e.g., Japan Disaster), further support this enhanced strength.

Additional improvements appear to be required in terms of the capacity of P/T laboratories. Reports were that data can now be shared more easily during foodborne illness incidents; however, not all P/T laboratories have the capacity to implement new testing methods developed in the National Microbiology Laboratory (NML). Some P/Ts prefer to send samples to the NML for new methods testing.

Conclusions:
The ability to manage and respond to foodborne illness has strengthened. Personal level and inter-departmental relationships have been strengthened and fostered. P/T laboratory capacity is an area that can be improved.

4 Recommendations

The findings of this evaluation point to positive improvements in inter-departmental interfaces since the 2008 listeriosis outbreak. In addition to these marked improvements and enhancements, several areas for improvement were also identified. The recommendation provided in this section aims to further improve the management and coordination amongst F/P/T partners during foodborne illness outbreaks.

4.1 Review F/P/T MOUs to determine if a higher level of consistency can be attained

The F/P/T MOUs between the CFIA and the P/Ts should be reviewed to determine if certain components can be made more consistent. Aligning the MOUs, to the extent possible, will help to clarify the expectations of various partners involved in emergency management of foodborne illness outbreaks. This would be particularly valuable to those working on food investigations at the federal level who deal with P/T health ministries and laboratories. A possible forum for identifying common ground would be an expanded set of table-top exercises.

Appendix A - Evaluation Matrix

Program Design (Processes and Procedures, Governance Structures)
Evaluation Questions Indicators Methodologies Data Sources
1. Are the processes and procedures clearly documented and executed?
  • Documentation that clearly explains process and procedures
  • Evidence of processes followed
  • Document review
  • Interviews
  • FIORP
  • CFIA Food Investigation Response Manual
  • CFIA Emergency Response Plan
  • CFIA Framework for Food Safety and Response
  • Mock exercise results
  • Stakeholder interviews
2. Are there appropriate governance structures in place and how effective are they?
  • Type of governance in place, and their respective purposes
  • Number and types of issues related to process
  • Document review
  • Interviews
  • Case studies
  • Governance documents
  • Strategic interviews
  • Stakeholder interviews
  • Previous emergency response incidents
3. Are the roles and responsibilities clearly documented and understood?
  • Documentation describing roles and responsibilities of those involved in emergency management
  • Opinions of those involved in undertaking emergency management activities
  • Document review
  • Interviews
  • Case studies
  • FIORP
  • Strategic interviews
  • Stakeholder interviews
4. How effective is the decision-making process?
  • Opinions of those involved in delivery of emergency management activities (front-line)
  • Level of duplication of any processes or procedures
  • Document review
  • Interviews
  • Case studies
  • Mock exercise results
  • Strategic interviews
  • Previous emergency response incidents
Success (Immediate and Intermediate Outcomes)
Evaluation Questions Indicators Methodologies Data Sources
5. Is there an identified Government of Canada lead to coordinate federal response efforts?
  • Identified lead for response efforts
  • Document review
  • Interviews
  • FIORP
  • Stakeholder interviews
6. Has the F/P/T management of foodborne emergency response improved?
  • Issues identified during mock exercises compared to Weatherill Report findings
  • Opinions of those involved in emergency response
  • Document review
  • Interviews
  • Case studies
  • Mock exercise results
  • Stakeholder interviews
7. Is there improved coordination of F/P/T emergency response to multi-jurisdictional food-borne illness outbreaks?
  • Issues identified during mock exercises compared to Weatherill Report findings
  • Opinions of those involved in emergency response
  • Lessons learned and good practices
  • Document review
  • Interviews
  • Case studies
  • Mock exercise results
  • Stakeholder interviews
8. Is there strengthened intra- and inter-jurisdictional ability to manage and respond to foodborne illnesses?
  • Issues identified during mock exercises compared to Weatherill Report findings
  • Opinions of those involved in emergency response
  • Lessons learned and good practices
  • Document review
  • Interviews
  • Case studies
  • Mock exercise results
  • Stakeholder interviews

Appendix B - Interdepartmental Evaluation Advisory Committee Members

The following members comprise the Interdepartmental Evaluation Advisory Committee:
CFIA - Audit, Evaluation and Risk Oversight Peter Everson (Co-Chair) ED, Audit, Evaluation and Risk Oversight
CFIA - Policy and Programs Branch John Lynch (Co-Chair) ED, Food Safety and Consumer Protection Directorate
CFIA - Operations Harpreet Kochhar A/Executive Director, Operations Strategy and Delivery
CFIA - Public Affairs James Stott Director, Program Communications
CFIA - Science Diane Allan ED, Food Safety Science Directorate
Health Canada Perfecto Vélez Macho Senior Evaluation Analyst, Departmental Performance Measurement and Evaluation Directorate
CFIA - Audit, Evaluation and Risk Oversight Joanne Roulston Director, Corporate Evaluation

Appendix C - Documentation Reviewed

The following documentation was reviewed:

  • Canada's Foodborne Illness Outbreak Response Protocol (FIORP);
  • CFIA's Emergency Response Plan;
  • CFIA's Food Investigation Response Manual;
  • CFIA's Framework for Food Safety Investigation and Response;
  • Report of the Independent Investigator into the 2008 Listeriosis Outbreak;
  • Report of the Standing Committee on Agriculture and Agri-Food, "Beyond the Listeriosis Crisis: Strengthening the Food Safety System;"
  • Results of exercises completed as part of FIORP; and
  • 2010 Fall Report of the Auditor General of Canada: Chapter 9 - Animal Diseases.

Appendix D - Strategic Interviews Interview Guide

Evaluation of Food Safety Inter-Departmental Interfaces
Interview Guide for Strategic Interviews
May 20, 2011

Design

1. Do you believe that key stakeholders understand their role when it comes to emergency management specific to foodborne illness outbreaks? Are there areas where clarity is lacking? If so, what are these areas?

2. Are there mechanisms in place to enforce the FIORP, such as policies, operating procedures or terms of reference, generally, or specifically, for FIORP duty officers?

3. Does the Outbreak Investigation Coordinating Committee (OICC) consist of the same members each time it is formed and disbanded? Are measures in place to ensure continuity or knowledge transfer?

Success

4. Are exercises (on-site or tabletop) related to emergency management specific to foodborne illness outbreaks currently carried out? If so, by whom and at what frequency? How are the results used?

5. The CFIA Framework for Food Safety Investigation and Response does not seem to directly respond to Weatherill Recommendations 50 and 51. Is there additional information you can share, which demonstrates specifically what CFIA has done to respond to these recommendations?

6. How long has CFIA had a Food Investigation Response Manual and Emergency Response Plan in place? Were these available during the 2008 outbreak? Have these documents been approved as final versions? If not, what is the status?

7. Do you have any other comments related to measures related to the effectiveness of inter-departmental and inter-jurisdictional interfaces during a food safety incident, implemented between 2009-10 and 2010 11?

Appendix E - Stakeholder Interview Guide

Evaluation of Food Safety Inter-Departmental Interfaces
Draft Interview Guide for Stakeholder Interviews

General

1. Please provide a brief description of your roles and responsibilities?

2. What has been the extent of your involvement in emergency management of foodborne illness outbreaks?

Design

3. What documentation do you refer to in order to understand the processes and procedures that exist with respect to emergency management of foodborne illness outbreaks? Are processes, during an event, documented? If so, in what ways? [Q1]

4. What are the key governance structures that guide emergency management of foodborne illness outbreaks? How effective do you believe each of these structures to be, on a scale of 1 to 5 where 1 is equal to not at all effective and 5 is equal to highly effective? Please explain your responses. [Q2]

5. Are there any specific processes that are more ineffective than others? If so, which ones and why? Are processes duplicated? If so, which ones? [Q2; Q4]

6. Do you have a clear understanding of what your roles and expectations are when it comes to emergency management specific to foodborne illness outbreaks? Are there areas where clarity is lacking? If so, what are these areas? [Q1; Q3]

7. Are there specific documents that you can refer to, which describe what your roles and responsibilities should be? If so, what are these documents? [Q1; Q3]

8. Do you believe that the decisions made, related to emergency management of foodborne illness outbreaks are effective? If so, can you provide specific examples? If not, why? [Q4]

Success

9. Are you aware of who is the identified lead for the Government of Canada in terms of coordinating federal response efforts related to foodborne illness outbreaks? [Q5]

10. Are exercises (on-site or tabletop) related to emergency management specific to foodborne illness outbreaks currently carried out? If so, by whom and at what frequency? How are the results used? [Q6]

11. Based on your experiences, would you describe the F/P/T emergency management of foodborne illness outbreaks to be stronger, weaker or the same as the situation during the 2008 listeriosis outbreak? Please explain your response. [Q6]

12. Based on your experiences, would you describe the F/P/T coordination during foodborne illness outbreaks to be stronger, weaker or the same as the situation during the 2008 listeriosis outbreak? Please explain your response. [Q7]

13. Can you provide any specific examples (or lessons learned) of improved F/P/T coordination, or identify any specific areas that are still in need of improvement? [Q7]

14. Based on your experiences, would you describe the overall intra- and inter-jurisdictional ability to manage and respond to foodborne illness to be stronger, weaker or the same as the situation during the 2008 listeriosis outbreak? Please explain your response. [Q8]

15. Can you provide any specific examples (or lessons learned) of strengthened intra- or inter-jurisdictional capability to respond to foodborne illness, or identify any specific areas that are still in need of improvement? [Q8]

16. Do you have any other comments related to measures relating to the effectiveness of inter-departmental and inter-jurisdictional interfaces during a food safety incident, implemented between 2009-10 and 2010-11? [General]

Appendix F - Key Findings Details

4.2 Design and efficiency

4.2.1 Are the processes and procedures clearly documented and executed?

4.2.1.1 Documentation support

Numerous key documents outline the processes and procedures associated with emergency management response to foodborne illness outbreaks, with the critical documents as follows:

  • Canada's Foodborne Illness Outbreak Response Protocol (FIORP), Section 7, describes inter-departmental operating procedures. The Protocol appears to be complete in describing processes and procedures that should take place during the emergency management of foodborne illness outbreaks. They cover components from the activation of the Outbreak Investigation Coordinating Committee (OICC) to the coordination of various investigations (epidemiological, food safety and laboratory).
  • The Canadian Food Inspection Agency (CFIA) Emergency Response Plan: This is a key CFIA document that describes how an emergency response is to be organized within the CFIA, including roles, responsibilities and structures that are to be put into place. It also describes the process for effectively conducting post-emergency assessments to determine lessons learned from incidents. It is clear, concise and comprehensive.
  • The CFIA Food Investigation Response Manual provides clear instructions on how to execute food investigations from the point of a triggered event to the point of potential recall. It provides detailed diagrams of various steps required in the investigation of food incidents. It is clear, concise and complete, and appears to be presented in chronological order.

Inefficiencies or areas for improvement which were identified through the documentation review:

  • A lack of clarity concerning when the Food Safety Communications Protocol should guide communications, and who should lead that implementation, as opposed to various department-specific communication protocols and vice versa.
  • Despite the completeness of the descriptions in the FIORP, the structure of Section 7 lacks clarity. The section could be structured in a way that more appropriately reflects the specific order in which processes would typically occur during an outbreak response. For example,there are numerous references to the OICC throughout the document, prior to a formal definition and description of the OICC in Section 7.4.
4.2.1.2 Interview support

The FIORP has been revised since the Weatherill Report was published. The FIORP appears to be widely recognized and accepted as the overarching document which communicates, guides and articulates the protocols that govern the roles, responsibilities, efforts, actions and inter-dependencies between and among these federal entities as well as the provinces and territories (P/Ts) in the event of responding to a foodborne illness outbreak. At least one interview noted, however, that the FIORP is not an enforcement document, that is, the FIORP is meant to guide a response, but it does not mandate action.

The CFIA, the Public Health Agency of Canada (PHAC) and Health Canada (HC) each have in place their own documentation to communicate, guide and articulate the protocols which govern the roles, responsibilities, efforts, and actions of those within their own organizations in the event of a foodborne illness outbreak, in addition to the FIORP.

Situation reports are also produced as part of the Incident Command System (ICS), a structure that is used to command, control, and coordinate the use of resources and personnel, and are prepared for the purpose of documenting incident decisions. These reports have reportedly improved in both the frequency and quality with which they are prepared. The reporting process has been reportedly formalized so that situation reports are produced for every meeting of the ICS, and they are shared with all those who need to be made aware of new developments related to incidents.

While the findings in this area are generally positive, improvements are needed to support P/Ts and local health units. Reportedly, the surveillance systems within P/Ts, and even local health units are inconsistent. For example, some doctors will focus on treating symptoms rather than doing systematic tests to determine the root cause of illness. This can result in a foodborne illness being reported late or not at all. There reportedly is a challenge in getting P/Ts to continue to fund surveillance activities, which may add to the inconsistency issue.

4.2.1.3 Case study support

The importance of documented processes and procedures is evident when comparing foodborne outbreak incidents between 2009 and 2011. Those interviewed as part of these case studies suggested that responses to incidents in 2011 were more efficient than in 2010. The difference in efficiency was largely attributed to the fact that the FIORP was not yet revised during the earlier response, but was available in revised state by the time the 2011 incident occurred, thus providing clearer direction and guidance on the response and management protocol, roles and responsibilities.

During the 2011 response, a communications issue arose. PHAC issued a bulletin warning the public to cook the product before consuming it, but the CFIA had already issued a recall, which meant the product should not be consumed. This created confusion in the media and the provinces. It is not clear that the Food Safety Communications Protocol was followed; however, it was reported that PHAC's Guidelines for Communicating with the Public and Those at Greater Risk were followed, in addition to departmental and agency communication protocols.

4.2.2 Are there appropriate governance structures in place and how effective are they?

4.2.2.1 Documentation support

The following key governance structures or committees were identified in the documentation reviewed:

  • Outbreak Investigation Coordination Committee (OICC): Chaired by PHAC; membership varies but typically includes the CFIA, HC, P/Ts and local public health units. OICC is the main forum for information-sharing and interpretation, clarification of roles and responsibilities, establishment of response priorities, and the development of outbreak communications. It is typically triggered when an investigation and response has the potential to be multi-jurisdictional and include a foodborne illness outbreak. Most outbreaks do not include an OICC.
  • Incident Command System (ICS): Chaired by the CFIA and membership varies, but typically includes PHAC, HC, P/Ts and local public health units in the event of a foodborne illness incident. A standardized organizational structure used to command, control, and coordinate the use of resources and personnel that has responded to the scene of an emergency (in a non-OICC situation). It is reportedly triggered at the discretion of the CFIA Senior Management.
  • Senior Food Safety Committee (including the Food Safety sub-committee): Chaired by the Chief Food Safety Officer and comprised of members of CFIA Senior Management. It is a forum for enhanced coordination across CFIA branches and final rulings on differing perspectives. It is triggered during high profile or complex food safety issues requiring the attention of the Office of the President of CFIA.

In addition to these key structures, the CFIA has adjusted its organizational structure to bring and enable improved governance, oversight and escalation or resolution of issues during routine incidents, as well as during emergency management incidents. As such, the Executive Director, Office of Food Safety and Recall, now reports directly to the VP, Operations, to provide a more direct linkage.

4.2.2.2 Interview support

The ICS was lauded by interviewees as a key governance structure that continues to improve. Traditionally, the ICS was not used for foodborne illness outbreaks, so there was a learning curve that continues to level off. Reportedly, its efficiency, with respect to foodborne illness emergency management, will continue to improve as it is invoked for more foodborne illness incidents.

The OICC, which is invoked and led by PHAC, is considered a strong component of the governance surrounding emergency management of foodborne illness outbreaks (though it is driven by public health concerns). Within the OICC, anyone with information is permitted to share within the forum. It brings together local and provincial science and medical people. It was reported that the OICC is not always invoked as early as possible, and does not always include the right people, because each outbreak is different, but improvements are ongoing, and it is viewed as effective.

The National Microbiology Lab (NML), part of PHAC, has become a central location for sharing lab information amongst partners. PHAC has MOUs with provincial labs. In addition, there is a PHAC database, administered by Pulsenet Canada, which permits partners to electronically obtain information and upload new information, which can be shared via a web portal.

The creation of the Senior Food Safety Committee was a direct result of the Weatherill Report. It is reported as highly effective in its role. This Committee was particularly effective in enhancing information sharing during the Japan incident (March 11, 2011, earthquake, tsunami and nuclear meltdown), which involved numerous partners, a number of whom were not particularly familiar with one another (i.e., the CFIA, Canadian Nuclear Safety Commission (CNSC), Public Safety Canada, the Department of Foreign Affairs and International Trade (DFAIT), and the Canada Border Services Agency (CBSA)). All interviewees rated this Committee as effective or highly effective.

From the reported lab perspective, improvements have been seen between federal (PHAC) and provincial public health agencies (P/T), federal food (CFIA) and federal public health agencies (PHAC), but not to the same degree between provincial food (P/T) and federal food agencies (CFIA). MOUs exist between the CFIA and each of the P/T partners, but there are privacy issues that prevent the CFIA from sharing certain food distribution information with P/Ts. Reportedly, the OFSR is working to resolve these issues and ensure stronger information-sharing with P/Ts.

4.2.2.3 Case study support

The governance structures in place in the case of a 2011 foodborne illness outbreak and the Japan Disaster (March, 2011) incidents reportedly worked effectively. Due to the timing of a 2010 incident, certain documentation (namely the FIORP) had not yet been revised (a second round of revisions came after this date). When an incident is contained to one province, a provincial Outbreak Investigation Coordinating Committee (OICC) may be called and led by the province, thereby not formally including PHAC. Consequently, without a current FIORP, there was some initial uncertainty about invoking the provincial OICC, which would be an option since illnesses were not detected in multiple P/Ts, and thus PHAC's OICC would not be invoked.

It is reportedly typical, in this situation, for an MOU to guide the investigation and response with the CFIA, but processes outlined in the MOUs are not consistent across all provinces, making it unclear as to what certain roles are at times.

Generally, it appears that each governance structure effectively serves a specific purpose and most are flexible enough to bring in additional partners as dictated by the situation (e.g., the Japan situation dictated the involvement of departments that would regularly not work with the CFIA - CNSC; DFAIT; CBSA).

4.2.3 Are the roles and responsibilities clearly documented and understood?

4.2.3.1 Documentation support

In the event of a multi-jurisdictional foodborne illness outbreaks, the FIORP (which was revised in 2009 following completion of the Weatherill Report) serves as the master authoritative source document with respect to the definition and documentation of roles and responsibilities of the CFIA, PHAC, HC and P/Ts.

The FIORP sets out key guiding principles and operating procedures for the identification and response to multi-jurisdictional foodborne illness outbreaks in order to enhance collaboration and coordination among partners. As well, FIORP establishes clear lines of communication, and strives to improve the efficiency and effectiveness of response to foodborne illness outbreaks.

Based on the review of the FIORP document, it is concluded that while the roles and responsibilities are relatively clear, some enhancements could be made. This is evident from the fact that we were required to ask clarification questions to those we interviewed as part of our strategic interview process. For example, the documentation does not clearly indicate the composition of the OICC and whether there is a need or means to ensure continuity or knowledge transfer.

The MOUs previously discussed also play a significant role in foodborne illness outbreaks. In the event of a foodborne illness outbreak involving only one P/T jurisdiction, MOUs between the CFIA and P/Ts as well as PHAC and P/Ts exist to define and communicate each party's respective roles. While MOUs are effective, there is a lack of consistency in their content. Due to the complexity and differences among P/Ts in their methods for dealing with foodborne illnesses, each MOU was designed separately. As such, the inconsistency can result in a lack of certainty about procedures at the federal level during food investigations.

Finally, the Standard Operating Procedure (SOP) for Directing Food Samples Collected during Epidemiological/Public Health/Food Safety Investigations to the Federal Laboratory Network was developed by the CFIA with input from PHAC and HC. This SOP provides a step-by-step process for testing food samples and lays out roles and responsibilities for laboratories.

4.2.3.2 Interview support

Overall, it appears there is a sound understanding on the part of those interviewed of the roles and responsibilities of each federal department/agency as well as P/Ts as it pertains to foodborne illness outbreaks that are national and federally led.

Overall, there is a belief among those interviewed that the completeness, clarity and understanding of the various roles and responsibilities have improved over the past two years; and these improvements have contributed to increasing the efficiency and effectiveness of the overall emergency response and management process.

It was noted, however, that while the table-top exercises have been conducted nationally, they have been conducted in each P/T exclusive of others as opposed to a situation in which all jurisdictions are involved in the exercise at the same time. As we heard from numerous interviewees, each P/T has its own foodborne illness structure and allocation of roles and responsibilities, and no two P/Ts are exactly alike. As a result, multi-jurisdictional table-top exercises would be an effective means of further clarifying and enhancing the understanding of the various roles and responsibilities.

Many interviewed stakeholders from the CFIA, PHAC, HC and P/Ts cited the recently conducted table-top exercises as having been highly beneficial to raising awareness about the FIORP, and individual and collective partner roles and responsibilities. Several interviewees noted a desire to plan and conduct more of these exercises in the future.

While the F/P/T partners are generally clear on their roles, it was reported that foods labs would like more guidance on their roles during a foodborne illness outbreaks. For instance, in January and February 2011 there was an incident related to a salmonella issue with eggs, in which the epidemiological investigation reportedly took very long, and it seemed that the labs were not well linked (3-4 provinces were involved). The implementation of the lab network of networks is reportedly progressing slowly, but the FIORP does not discuss their roles. There is reportedly no additional funding for the lab network of networks.

According to federal interviewees, some roles and responsibilities are reportedly less well understood when an incident is contained to a single province or territory. It was reported that roles are very clear during an outbreak response with federal leadership; however, in instances in which the illnesses are reported in a single P/T, the investigations are led by that P/T, and MOUs are used as guiding documents rather than the FIORP, and the role of the CFIA is less clear. In these situations, increased clarity of roles and responsibilities is required.

4.2.3.3 Case study support

The Japan situation (March 2011) was an international nuclear incident involving several international governments, several federal departments and agencies, and several Canadian provinces. The Canadian response as it related to the safety of food imports was led by the CFIA, an agency traditionally concerned with food safety (the overall GoC response was coordinated by Public Safety Canada). Given the uniqueness of the situation, we have learned that there were and are no clear guidelines on exactly which stakeholders should be involved in the response to this type of incident, and in what capacity they should be involved. That said, some interviewed stakeholders have cited the Canadian response as having been handled effectively and that it was such primarily as a result of the strong "human network" well documented and understood federal, provincial and territorial departmental and agency specific roles, responsibilities and protocols and partial activation of ICS. In short, the foundation was in place to respond to this unique situation.

There were a very limited number of reports about unclear roles in the Japan situation. It was reported that some staff working on the Japan incident were still unclear about their roles. It is particularly the case for individuals who have not yet participated in a response or exercise (new to a group). Also, the fact that this was an unprecedented incident meant that it took some additional time and attention to determine the best approach. The CFIA is close to finalizing Functional Plans, which will complement the FIORP and further guide processes related to foodborne illness outbreak response.

In the Japan situation, F/P/T communications related to food safety and public health aspects of the incident were coordinated by PHAC, while Public Safety Canada coordinated GoC communications globally. Reportedly, communications coordination was strong.

4.2.4 How effective is the decision-making process?

4.2.4.1 Documentation support

The documentation reviewed did not provide significant vidence to determine the effectiveness of decisions. While decisions are documented, in situation reports for example, there does not appear to be follow-up documentation that confirms the effectiveness of decisions, aside from conducting a hot wash, and the subsequent Management Response and Action Plan (MRAP), which allow for a formal debrief on lessons learned.

In a related matter, the CFIA has assigned responsibility for coordinating the review of lessons learned reports, which may include hot washes, to the Office of Emergency Management. This was primarily in response to an Office of the Auditor General Report entitled, "Animal Diseases".

4.2.4.2 Interview support

It was reported that sometimes decisions have to be made with minimal information, but with a potentially high level of risk. A recall decision generally cannot be made without strong evidence to support it. It was reported that this care can sometimes be construed as being overly precautionary, but there must be some flexibility to weigh the evidence and risks and make a decision accordingly. For example, in the lab context, salmonella enteritidis accounts for about 40% of all Salmonella incidents, but the lab test to DNA fingerprint this strand does not provide enough detail to conclude definitively that a number of people are sick with this same strain. The inability to draw a definitive conclusion makes decision-making more complex, which may lengthen the process.

Of course, different incidents require different types of responses and some require longer timelines before public communication can be made. For instance, before communications can be drafted and transmitted to the public, communications officials must wait for decisions by emergency management officials, who in turn wait for certain evidence before decision-making. Once decisions are made, though, communication must happen quickly, and coordination is required.

The interview data suggests that a lengthier timeframe is more appropriate than prematurely communicating information that may have a negative consequence. F/P/T partners might consider reviewing the approach taken from the time of investigation to the point of public communication in order to determine if changes are required, or desired.

The table-top exercises, which were led by PHAC and intended to inform decisions made with regard to FIORP revisions, are effective in informing such revisions. More of these exercises were said to have been completed since 2009 than in the preceding 20 years. The results of these exercises are documented and communicated through the Senior Food Safety Committee which as previously described, provides strategic direction and decisions during foodborne illness emergency management situations.

4.2.4.3 Case study support

The key example of effective decision-making from the cases reviewed was that of announcing a recall in the absence of direct sample evidence during a 2011 foodborne illness outbreak incident. Lab tests on the product samples produced no positive results for contamination; however, the lack of a positive result does not mean the product was safe for consumption. Other evidence indicated that the product was contaminated: consequently, a decision to recall was made. This example demonstrates how emergency management officials must occasionally make decisions based on limited evidence in combination with other considerations of public health. According to interviewees, only one additional illness was reported in connection to this incident once the recall had been announced. This result was viewed positively by all stakeholders who were interviewed.

4.3 Success and effectiveness

4.3.1 Is there an identified Government of Canada lead to coordinate federal response efforts?

4.3.1.1 Documentation support

The FIORP clearly indicates that PHAC is responsible for coordination of the emergency management of multi-jurisdictional foodborne illness outbreaks, and defines its specific roles, as well as those of other partners.

4.3.1.2 Interview support

Every individual interviewed indicated they were aware that PHAC is the federal lead in coordinating response efforts to foodborne illness outbreaks.

Many interviewees noted that the FIORP clearly outlines the roles and responsibilities of PHAC.

In the event that illnesses are confined to a single province or territory, PHAC does not lead: instead, the P/T in which the outbreak is occurring is responsible for taking the lead and as such has the option of voluntarily inviting PHAC to participate in the response efforts.

4.3.1.3 Case study support

According to interviewees at the CFIA and PHAC, it was as a result of PHAC's leadership during a foodborne illness outbreak in 2011, and the effectiveness of the OICC that the response to, and management of this incident was a success.

Reportedly, the OICC activated to address the incident was noticeably improved compared to that which was activated during the 2008 Listeria incident. The improvements identified through the course of developing this case study included:

  • The preparation of meeting minutes (situation reports), which were not always completed in 2008, according to interview data;
  • Extensive review of situation reports, which often were not reviewed following meetings of the OICC in 2008, according to interview data; and
  • Documented conference calls, which were not always formally documented in 2008, according to interview data.

4.3.2 Has the F/P/T management of foodborne emergency response improved?

4.3.2.1 Documentation support

The documentation reviewed does not specifically address this question. However, the quantity and quality of existing documentation (see Appendix C) to define foodborne illness outbreak response and management protocol, roles and responsibilities is a good indicator that foundational elements are in place to help enable sound F/P/T foodborne emergency response management.

Further, it was reported and we confirmed, that the following key documents have been developed, revised or enhanced in the past two years to help improve the management of foodborne illness outbreaks:

  • The FIORP update was developed by PHAC with input from the CFIA;
  • The "weight of evidence" document was developed by HC to inform HC in conducting Health Risk Assessments as part of investigations; and
  • The Policy on Listeria monocytogenes in Ready-to-Eat Foods was developed by HC to provide guidance to stakeholders (e.g. food safety regulators including the CFIA and P/T governments) regarding verification and control, as well as regulatory oversight and compliance activities for ready-to-eat foods with respect to their potential to support the growth of Listeria monocytogenes.

In addition, table-top exercises have been designed and documented through PHAC's leadership and in turn, rolled out nationally to and with F/P/T stakeholders to improve the management of foodborne emergency responses. Further, these exercises have contributed to revisions to and strengthening of the FIORP.

Following each foodborne illness incident, a "hot wash" or after-incident review is completed during which a debrief is formally conducted by the F/P/T partners, on the efficiency and effectiveness of the management of the incident. The hot wash results are shared with senior management, which then completes a Management Response and Action Plan (MRAP) for the hot wash. Ultimately, these hot washes lead to lessons learned for future incidents.

4.3.2.2 Interview support

A revised FIORP has led to a clearer understanding of roles and responsibilities, which has reportedly led to improved emergency response and management. All interviewees indicated that the management response to foodborne illness outbreak is stronger today than at the time of the 2008 Listeria outbreak, and this has been attributed to the FIORP. Individual stakeholders are more widely aware and have a more solid understanding of the Protocol today, due to the fact that it has become the standard for responding to foodborne illness outbreaks; thus they are more aware and clear about their respective roles and those of others than previously.

Other contributing factors to this improved management include:

  • PHAC-led simulations and table-top exercises;
  • An expanded lab networking on the F/P/T side, which allows for sharing methods, and helping labs increase capacity and capability;
  • The CFIA's National Emergency Operations Centre (NEOC) is now used for food-related incidents, whereas previously it was used only for animal-related outbreaks;
  • Regular dialogue between F/P/T partners (first workshops in spring 2011); and
  • F/P/T ADM Food Safety Committee has been established (DG and director-level committees also exist, but existed in 2008 as well).

Another example of F/P/T management is the Province of Ontario whose Ontario Multi-Agency Working Group holds a weekly teleconference to discuss issues related to foodborne illnesses. It includes the CFIA, HC, the Ontario Ministry of Health and Long Term Care, Public Health Ontario and the Ontario Ministry of Agriculture, Food and Rural Affairs.

4.3.2.3 Case study support

As previously explained, an analysis comparing a 2009 foodborne illness outbreak incident and one in 2011 provided evidence that the FIORP has had a significant impact on improving the F/P/T management of foodborne emergency responses. Those interviewed as part of these case studies suggested that the 2011 response was more efficient than the 2009 response, largely attributed to the fact that the FIORP was not yet revised during the earlier response, but was available in revised state by the time the 2011 incident occurred.

The 2009 incident was not reported as poorly managed, despite reports that there was considerable room for improvement. In fact, the early involvement of partners was identified as a key success. Additionally, communication was noted as successful, with recall notices going out without issue. Despite these positive attributes, there were several reported areas for improvement. These areas included the need for better information sharing between provinces and the CFIA with respect to product distribution, however, the CFIA was unable to provide distribution data to the province due to issues related to personal privacy.

Another area for improvement was a concern regarding duplication of some tasks as the response moved from the planning stage to the operational stage. The ICS consists of a planning cell, which handles early information processing, including sampling and testing, and an operations cell which manages the incident once enough evidence exists to move forward. It was reported that during the Siena Foods incident, the cells were not comprised of individuals with the skill set required to fulfil specific roles associated with each cell. Moreover, there were separate planning cells - one for the CFIA Ontario Area and one for the CFIA Headquarters, but they were not well-coordinated, resulting in duplication of work. In addition, the Office of Food Safety Recall (OFSR) was unsure where it fit into the investigation. Some of its specific activities were duplicated in the planning cell and operations cell, due to the uncertainty. However, since the time of this incident, the OFSR has become more involved in both the planning and operations cells, thus preventing duplication of work.

The reported weaknesses of the 2009 response were, at least in part, attributed to the fact that the FIORP and other documents were still being revised or developed; therefore, the information contained within those documents was not well-known.

By the time the 2011 incident occurred, these documents were in place and finalized, and consequently, the response was managed much more efficiently, according to interviewees. Many interviewees attribute the difference in management efficiency to the existence of these documents.

4.3.3 Is there improved coordination of F/P/T emergency response to multi-jurisdictional food-borne illness outbreaks?

4.3.3.1 Documentation support

The FIORP is a critical document for improving F/P/T coordination in emergency response. The Food Safety Communications Protocol, a component of the FIORP, is also a highly valuable tool for coordinating communication during outbreaks. The Food Safety Communications Protocol is in place to improve coordination by clarifying roles and responsibilities for joint communications on food safety issues that involve the CFIA, HC and PHAC, and to establish a scalable approach for partners to follow in developing joint communications plans and products on food safety issues. Based on our review and assessment, it is clear and comprehensive, and is expected to contribute to a more consistent communications approach by partners involved in outbreaks of foodborne illness emergency management.

Table-top exercise results indicate good participation rates by P/Ts. More than 640 participants representing the broad spectrum of roles typically involved in a multi-jurisdictional foodborne illness outbreak investigation attended these exercises, which were held between January and April 2011 in all 13 P/Ts. Participants included medical officers of health, program managers and directors, public health inspectors, food safety specialists, epidemiologists, public health nurses, communications staff, microbiologists and laboratory technologists, as well as others. Scenarios were reportedly different for each exercise. A summary report of these exercises indicates that participants considered them an effective learning tool (97.6%). Additionally that summary report indicates that 94.4% of participants who responded to a post-event questionnaire will incorporate material learned from the exercises into future outbreak investigations.Footnote 1

Despite the benefits of these exercises, there is room to enhance their effectiveness. Currently these exercises are completed within P/Ts and separate from one another. Table-top exercises or similar events should be held with multi-jurisdictional partners present at a single event. This would further encourage information sharing amongst key partners.

4.3.3.2 Interview support

All interviewees indicated that F/P/T coordination in emergency management is stronger than during the 2008 listeriosis outbreak. It was reported that the system has been tested over the last 2 ½ years with several incidents, as reported throughout this document. Most have involved only one or two provinces, but the OICC was triggered several times. The response has reportedly worked very well, despite some minor challenges remaining around the timing of meetings and timing of sharing information, but the processes are there, and people are regularly reminded of the protocols.

In addition, PulseNet Canada is a virtual electronic network which ties the public health laboratories of all provinces (plus some federal laboratories) together by linking their computers and databases. Provinces can now upload their data and share it easily, which has improved coordination, particularly during epidemiological investigations. This network has been a significant enhancement to the coordination of provincial and some federal laboratories.

Despite these positive findings on coordination, there are areas for improvement. Several interviewees indicated that provinces still require guidance around certain situations. For example, it was noted that there is at least one incident in which a representative of a provincial ministry of health phoned the President of the CFIA directly, when they should have coordinated with the CFIA provincial area representative.

In addition, there was some indication that the CFIA may be able to put an added planning and training emphasis on non-meat sectors. Two interviewees indicated that the federal government has not focused enough in the non-meat area, especially regarding products sold in a single province. A lot of work has gone into improving the meat program, but much less for dairy, fish, etc. Reportedly, there is less capacity in this area and fewer inspectors.

4.3.3.3 Case study support

The food safety component of the Japan incident contained numerous key examples of strong F/P/T coordination. For instance, the relationship between the CFIA and CBSA reportedly matured to a great extent during this incident. The CFIA relied on CBSA's knowledge and skill in the area of border control during the course of the incident, and decisions related to the importation of food products from Japan were made in conjunction with CBSA officials. The collaboration resulted in border lookouts which, among other benefits, allowed for border officers to receive new information from the CFIA instantly on their computer screens. This was important for the response, so that information could be conveyed rapidly to front-line workers, when necessary. On-going dialogue also occurred between CFIA and CNSC.

There were also successes identified between governments, as this incident was global in nature. The CFIA's International Policy Directorate, in conjunction with DFAIT engaged in regular communication with the Japanese embassy on actions taken by the CFIA. This was effective in providing Canadians abroad with information about food safety.

Interpersonal relationships were fostered throughout this incident due to its unprecedented nature, as individuals were forced to learn and act together as the response moved forward. As previously described, this incident brought together departments and agencies that were not familiar with working with one another, yet the management of the response was very positive by those who were interviewed as part of the case study.

4.3.4 Is there strengthened intra- and inter-jurisdictional ability to manage and respond to foodborne illness?

4.3.4.1 Documentation support

Each of the documents identified in this evaluation (and previously discussed in this report) appear to position the GoC and its partners to effectively manage and respond to foodborne illness outbreaks.

Key documents:

  • Foodborne Illness Outbreak Response Protocol;
  • CFIA Emergency Response Plan;
  • CFIA Food Investigation Response Manual;
  • Food Safety Communications Protocol (PHAC);
  • Weight of Evidence Document (HC);
  • Policy on Listeria monocytogenes in Ready-To-Eat Foods (HC);
  • MOUs between PHAC and P/Ts; and
  • MOUs between the CFIA and P/Ts.
4.3.4.2 Interview support

It was reported that in some cases personal relationships are being formed across departments and jurisdictions, and that these had had a positive effect on enhancing the ability to manage and respond to foodborne illness. There should be a continued focus on the personal level relationships, which have largely been possible as a result of table-top exercises where individuals are brought together. As one interviewee indicated, people are now engaged vertically within departments and jurisdictions, and also horizontally across departments and jurisdictions.

From a laboratory perspective, while PulseNet Canada has helped to enhance information sharing through a central location (NML Winnipeg), the adoption of new methods (developed by the NML) by some P/Ts is lacking. In some instances, P/Ts prefer to send samples to the NML for new methodological testing, in part due to capacity issues. There is reportedly still room to improve laboratory networking despite the network of networks, a Weatherill recommendation, the implementation of which is still in the infancy stages. The Standard Operating Procedure (SOP) for Directing Food Samples Collected during Epidemiological/Public Health/Food Safety Investigations to the Federal Laboratory Network was finalized in 2011, and provides a list of procedures and roles for laboratories.

In addition to these findings, the findings associated with questions 6 and 7 also support a strengthened intra- and inter-jurisdictional ability to manage and respond to foodborne illness.

4.3.4.3 Case study support

As explained previously in this report, from an analysis of the responses from a 2011 foodborne illness outbreak incident, compared to an earlier one in 2009 and to the 2008 listeriosis outbreak, it can be concluded that continual improvements in the intra- and inter-jurisdictional ability to manage and respond to foodborne illness outbreaks have occurred, based on descriptions provided by interviewees.

With each incident, notable gains have been identified. Examples include:

  • A clearer understanding of roles and responsibilities by partners (2011 incident);
  • The speed with which partners were identified and brought into the response team (2009 incident); and
  • The fostering and burgeoning of new and existing relationships amongst federal departments and agencies facing an unprecedented situation (Japan Disaster).

Finally, it was indicated by many interviewees that the existence and continuous revision of key documentation, namely the FIORP, has been critical to these improvements. It has helped to delineate roles, responsibilities and expectations which has, in turn, improved emergency management response.

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