Independent Review of XL Foods Inc. Beef Recall 2012

Ronald John Lewis, DVM
(Chair) André Corriveau, MD
W. Ronald Usborne, PhD

May 2013

Table of Contents


Acknowledgements

As the following pages reveal, the Panel was assisted greatly by the efforts of Canadian Food Inspection Agency (CFIA, or Agency) staff – whether in our communications with various government departments, to source additional information, or simply to organize travel arrangements and accommodate our meeting space requirements.

We particularly acknowledge the efforts of CFIA staff members Brian Evans, Scott Rattray and Marlene Longtin at National Headquarters in Ottawa, and Western Area staff member Wendy Fairs in Calgary for their assistance. These individuals at all times acted at arms' length and took great pains not to interfere in any way with the independence of this review.

The Panel was greeted by the organizations and individuals listed in Appendix III with candour and enthusiasm, and a willingness to assist in providing all the information we requested – often more. The Panel frequently approached the same individuals to confirm or follow up on information, which they provided to the best of their ability.

We believe all of these organizations and individuals were motivated by the same goal: enhancing the food safety system for the benefit of all Canadians. We thank them all sincerely for their assistance to the Panel, as well as for their ongoing efforts to continue to improve food safety in Canada.

Finally, the Panel thanks Catherine Barratt for her excellent writing skills, dedication to tasks, and enthusiasm in organizing and assembling a great deal of information into a coherent package.

Executive Summary

The Panel members were appointed by the Governor in Council to undertake an independent review of the beef recall that occurred at XL Foods Inc.'s plant at Brooks, Alberta between September and October 2012, and to submit a report to the Minister of Agriculture and Agri-Food.

We were asked to establish how the contamination occurred and, moreover, how the Canadian Food Inspection Agency (CFIA, or Agency), its food safety partners, and XL Foods Inc. responded to the situation. Lastly, we were tasked with providing recommendations that would address any findings or conclusions that we had made regarding these matters. We note that such findings or conclusions do not address civil or criminal liability; the standards that we are applying are not legal ones.

Over the course of several weeks, the Panel met with dozens of stakeholders. These included beef producers and processors, health authorities and academics, the retail industry, and union representatives for both the company and the Agency.

In this regard, we were left with a single overarching impression: everyone we interviewed expressed a keen desire to ensure that the food Canadians eat is safe. And they all wanted to be considered partners in the pursuit of that goal.

This is reassuring for the Canadian consumer; in fact, several industry representatives we met made the same remark: "We don't view food safety as a competitive issue."

Yet, it was a series of inadequate responses by two key players in the food safety continuum that played the most critical part leading to the September 2012 event at XL Foods Inc. – plant and CFIA staff.

We found that responsibilities towards food safety programs were not always met – by both plant staff and CFIA officials on site.

We found a relaxed attitude towards applying mandatory procedures – clearly outlined in some documents, less so in others. Again, a shortcoming shared by both plant and CFIA staff.

We found one of the country's largest beef processors unprepared to handle what turned out to be the largest beef recall in Canadian history. As the company had never conducted any mock recalls on a scale that remotely mimicked a real event, XL Foods Inc. found itself overwhelmed with the recall that occurred.

In short, we found a weak food safety culture at the Brooks plant, shared by both plant management and CFIA staff.

In our view, the establishment of a strong food safety culture must be a goal shared by both parties if it is to succeed; each player in the continuum must do his or her part. Problems are inevitable if an individual at one station overlooks a problem in the expectation that someone at the next one will address it. The chain is only as strong as its weakest link.

It must be said that, overall, the incident revealed some of the strengths of Canada's food safety system – from monitoring and surveillance, to recall and incident management – but it also revealed several weaknesses. Available documents clearly outline the processes that must be in place, the consultations that are to occur, and that the Public Health Agency of Canada is to lead communications in a national foodborne emergency, etc. All these must work in a tightly coordinated and synchronized manner if Canadians are to have confidence in the food safety and public health authorities that serve them.

The Panel heard from players across both the food safety and supply spectrum, and was left with a very real sense that collaboration across the continuum can work. It remains for us to resolve how they can work together as partners to make recalls an infrequent event (if not a thing of the past) and, when they do happen, to address them in a coordinated, orderly, effective and efficient way.

We believe that the recommendations outlined in this review, if adopted, address the issues we have identified. Policies and procedures alone, however, will never meet their intended objectives if they are not adhered to and followed consistently.

Image - Signatures of Ron Lewis, DVM, André Corriveau, MD and Ron Usborne, PhD

1 – Introduction

Background

What would soon become the largest recall of beef and beef products in Canadian history began on September 4, 2012 at a Brooks, Alberta beef processing plant owned and operated by XL Foods Inc.

By October 15, beef processed at the plant and contaminated with Escherichia coli (E. coli) O157:H7 had made 18 consumers sick. Some 1,800 products had been removed from the market in Canada and the United States, as the result of several expansions of a voluntary recall by XL Foods Inc. and supported by the Canadian Food Inspection Agency (CFIA, or Agency).

That day in early September, CFIA inspectors received confirmation of the presence of E. coli O157:H7 in raw beef trimmings tested days earlier at the Ginger Beef Choice Ltd. plant in Calgary, a secondary beef processor. They quickly traced the raw product back to XL Foods Inc.'s Brooks plant. This finding triggered a CFIA investigation to determine whether beef from the same batch was on the market.

Coincidentally, the same day, Agency officials were notified by counterparts within the United States Department of Agriculture's Food Safety and Inspection Service (USDA FSIS) that they too had found E. coli O157:H7 in trimmings exported by XL Foods Inc. to the United States.

CFIA determined that the contaminated batch tested by FSIS had not been distributed in the Canadian marketplace. Based on these confirmations, both XL Foods Inc. and the Agency chose not to issue a public recall at the time, because no beef from either of the two tested batches was on Canadian store shelves. Meanwhile, CFIA began to look into the possible source of the contamination.

At the time, this action seemed sound and reasonable. In the days and weeks to come, the processing dates associated with contaminated beef would expand, public recalls and alerts would be issued, and some 4,000 tonnes of beef and beef products would be recalled from Canadian, United States and other international markets. This figure represents, at minimum, 12,000 head of cattle.

All of this prompted many to ask – long before it was over – if the event could have been prevented or managed better. Did 18 people need to get sick? Did so much meat have to end up in landfills? What went wrong, and how could we make sure that it doesn't happen again?

It was not that long ago – 2008, in fact – when an outbreak of Listeria bacteria took the lives of 23 Canadians and led to serious illness in 57 others that had eaten tainted meat products (i.e., ready-to-eat) prepared by Maple Leaf Foods. That event shook the nation and prompted the federal government to commission an independent investigative review of Canada's food safety system. That review, led by Sheila Weatherill, yielded the 2009 Report of the Independent Investigator into the 2008 Listeriosis Outbreak (the "Weatherill Report"); it is widely recognized for its comprehensive and rigorous investigation of both the circumstances of the outbreak and the nation's foodborne emergency response system. Because of its extensive explanation of areas such as our food supply chain, Canada's food safety system, and the roles and responsibilities of its partners, this Panel will have occasion to refer readers to the Weatherill Report.

As Ms. Weatherill comments in her report, Canada's food safety system – then, as now – is recognized as one of the best in the world. Yet, a mere four years later, Canadians found themselves asking how this could have happened once again.

It must be said that, while this E. coli O157:H7 contamination of beef products from the Brooks plant resulted in 18 people becoming sick, the beef recall was triggered well before any cases of human illness had been reported. This is important because, had it been launched only after illnesses were reported and contaminated products still in retail distribution, it is very likely that more consumers would have purchased and consumed product, resulting in even more illnesses.

It is also fair to note that, overall, foodborne E. coli O157:H7 infections have been declining considerably for several years – due in large part to our food safety system and the best practices of the beef-processing industry in general. In fact, recalls of beef contaminated with E. coli O157:H7 are now very infrequent. In contrast, the presence of the bacteria in fruits, vegetables and other non-beef products is on the rise and now accounts for the majority of human exposures causing illness. The Panel will have more to say about this in our recommendations. A paper by Doyle et al. (Food Research Institute, University of Wisconsin) contains the following charts that reflect the number of illnesses caused by E. coli O157:H7 worldwide from 1982 to 2006, and the source of the pathogen; these are reproduced below.

E. coli O157:H7 Cases Worldwide, 1982 – 2006

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Figure 2a: Escherichia 0157:H7 cases worldwide, 1982-2006
Figure 2a – E. coli O157:H7 cases worldwide, 1982-2006

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Figure 2b: Escherichia coli 0157:H7 cases worldwide, 1982-2006
Figure 2b – E. coli O157:H7 cases worldwide, 1982-2006

Food Research Institute, UW-Madison, August/October 2006
Funded in part by the American Meat Institute Foundation Corresponding author: M. Ellin Doyle, Ph.D., medoyle@wisc.ed:
http://fri.wisc.edu/docs/pdf/FRIBrief_EcoliO157H7humanillness.pdf

Impact of the recall on consumers

Certainly, the 18 people that became ill after eating contaminated beef were most directly affected. However, the rolling recalls, numerous public health hazard alerts, and extensive media coverage all created alarm and confusion among consumers as a whole. Public confidence in the beef industry, as well as in Canada's food safety system, was further eroded as a consequence of this incident.

A number of consumer polls in the ensuing weeks and months bore this out consistently. Some shoppers stopped buying beef altogether; others began instead to buy locally from small beef producers, because they reported feeling more confident about the safety of the product.

Domestic consumption of beef has been on a steady decline since its heyday in the 1970s, to be replaced to some degree on dinner plates by other meat proteins such as fish, or by more fruits and vegetables. If consumers feel they have reason to worry about the safety of the beef sold in our grocery stores, that decline is likely to continue.

Web-based citizen forums on a wide range of issues are now plentiful, and groups concerned about the safety of the food they eat number among them. These platforms provide both members and the web-browsing public with a vast quantity of previously inaccessible information about the beef industry, along with information about the risk of E. coli O157:H7 contamination in their meat.

Impact of the recall on the beef industry

For many of the same reasons, the country's beef industry, which represents a significant component of our economy, was also greatly affected by the XL Foods Inc. recall. In 2011, farm gate sales of beef in Canada were worth some $6 billion. While this figure is impressive, beef consumption is down not only in Canada (our domestic herd is now 20% smaller than in 2005), but globally as well. Indeed, world confidence in the safety of our beef is now as important to the industry as that of Canadians. The XL Foods Inc. recall was felt as far afield as Japan and Hong Kong immediately after it happened, to name just two of the more than 20 countries that imported the company's products.

With each recall that closes a plant, cattle producers that sell to large processors such as XL Foods Inc. also suffer. The cost of feeding market cattle can add up quickly. Each day that cattle are held back from processing adds to the producer's feed costs. The balance of supply and demand shifts as more cattle becomes available for market, negatively affecting the price producers get for each animal. A study commissioned by the National Cattle Feeders Association examined the effect of the XL Foods Inc. recall and plant closure. In addition to daily market quotations, losses to the beef industry were estimated in this study at between $16 million and $27 million.

Because the XL Foods Inc. Brooks plant represented 35% of Canada's beef processing capacity, producers were forced to send their cattle either to the only other major processor in Alberta, or to the United States. Well aware that cattle producers had few processing options and large numbers of animals ready for market, these alternate processors paid lower prices per head. This had a major impact on beef producers already operating on small profit margins.

Impact of the recall on the food safety system

Last but not least, Canada's food safety system has been affected by this and other recalls. Polls suggest that, despite the actual decline in the incidence of E. coli O157:H7 illnesses caused by food, over 50% of participants believe that cases are actually on the rise. In fact, Canadians place E. coli O157:H7 contamination at the top of their food safety concerns. And, while recent polls confirm that most consumers remain "confident" or "somewhat confident" about our food safety system, any loss of confidence affects the system's ability to effectively reach the public and change behaviour.

2 – Our Mandate and Approach

Our mandate

The Minister of Agriculture and Agri-Food Canada asked the Panel to find answers to three questions.

On the surface, the first and principal one the Panel was to investigate was straightforward:

"How did E. coli O157:H7-contaminated beef find its way out of the Brooks, Alberta plant in September 2012 and onto store shelves?"

As Chapter 4 of this report describes in detail, however, Canada's food safety system is very complex – one that involves multiple partners, each playing a critical role to ensure that everything possible is done to deliver food safe for consumers.

A copy of the Panel's Terms of Reference can be found in Appendix I of this report.

Each partner is responsible for activating a program, applying regulations, a policy or protocol; performing tests, notifying or educating the public, or exchanging information – all of which must be carried out effectively if food safety is to be ensured.

So, while the question may be straightforward, the path to finding the answer would prove otherwise.

Armed with the answer to this question, we would then address the following two:

"Was it reasonable to expect that the Canadian Food Inspection Agency (CFIA, or Agency) or XL Foods Inc. could have detected the contamination before the beef entered the market?"

and

"How effective was CFIA's response to the outbreak (given the additional resources it received in 2006), along with its food safety system partners?"

Our approach

To discover how the contaminated product was able to leave the plant, we needed to understand thoroughly from CFIA and XL Foods Inc. officials the processes in place at the facility at the time. It remained for us to determine how robust these were, to what extent a breakdown might have occurred, and/or whether existing systems were adequate to meet the food safety needs of Canadians.

We met with and interviewed extensively both Agency and company officials to establish what happened on the plant floor.

A complete list of those we interviewed may be found in Appendix III of this report.

The Panel also felt it was important to hear the views of stakeholders that play an important part in the beef industry. On learning of our review, they met our requests to speak with them with enthusiasm and full collaboration. Organizations included the Canadian Cattlemen's Association, the Retail Council of Canada, and the Canadian Meat Council, among others.

All these, and many more players in the beef and beef products supply chain, have a vested and keen interest in ensuring food safety, and all showed clearly their desire to be partners in the system.

With their valuable observations and our extensive review of documentation, protocols and policies, we met the final objective set for us by the Minister, to:

"Make recommendations, within the existing resources of the CFIA, to strengthen prevention strategies and regulatory oversight."

Our recommendations can be found in Chapter 8 of this report.

3 – Risk Factors Associated with E. coli O157:H7 Considered in this Review

Before delving into the risk factors associated with E. coli O157:H7 contamination of meat that underlay the need for this review, the Panel would like to present the following general understanding of the bacterium to help place it in the appropriate context.

E. coli O157:H7 – What it is, and how it is transmitted

Generic E. coli are found naturally in the intestines of cattle, poultry and some other animals, as well as in humans and, in fact, are a vital component of the digestive system. Although most E. coli are harmless to people, some strains of the bacteria (such as E. coli O157:H7) are pathogenic (that is, they can cause disease), and often trigger severe stomach cramps, diarrhea and vomiting. Diarrhea is initially non-bloody, but may soon increase in severity. Symptoms generally begin to appear three to four days after exposure, and the individual may remain ill for one to two weeks. E. coli O157:H7 infections have also been associated with kidney failure (Hemolytic Uremic Syndrome, or HUS), blindness, and even death.

Fortunately, the XL Foods Inc. recall did not result in any fatalities.

As in the case of most infection, severe illness is more commonly seen in the very young, old, and infirm, as well as pregnant women. Children can be particularly severely impacted. HUS is often attributed to E. coli O157:H7 infection, and usually occurs in children less than ten years of age. E. coli O157:H7 triggers the severe loss of red blood cells and platelets, as well as acute kidney failure typical of HUS.

About half of those who develop HUS will require dialysis. Complications that arise from the syndrome can include seizures, coma, and stroke, among others. HUS can become a chronic condition, meaning that kidney problems may return to affect the individual throughout life.

When animals are butchered at a processing plant, care must be taken not to allow the hide to come into contact with the beef during removal, and the animal's gastrointestinal tract must not be cut or ruptured, which helps prevent the bacteria from contaminating the meat itself.

The unusually virulent enterohemorrhagic strains of Escherichia coli, including the O157:H7 serotype, have prompted food microbiologists to rewrite the rule book on food safety. These pathogens are more significant than other well-recognized foodborne pathogens for reasons including the severe consequences of infection that affect all age groups, their low infectious dose, their unusual acid tolerance, and their apparent special but inexplicable association with ruminants that are used for food.

Robert L. Buchanan and
Michael P. Doyle

The bacteria have yet another opportunity to spread once the beef is processed. In the mechanical tenderizing process, E. coli O157:H7 can be transferred either from the surface of the meat or from contaminated needles or blades to the interior of the meat. A potential link has been made in recent E. coli O157:H7 cases to mechanically tenderized beef products, demonstrating that these products may represent a different level of risk relative to intact beef cuts.

Lastly, meat handled by a person with poor hygiene habits or who is infected with E. coli O157:H7 can also become contaminated.

The most common way for a consumer to come into contact with E. coli O157:H7 is by improper handling of raw ground beef and/or eating undercooked ground beef.

Fruits and vegetables may also be contaminated with E. coli O157:H7. In fact, it has been demonstrated that most cases of human illness originate from sources other than beef.

Manure that has not been properly composted, and water, wildlife or harvesting equipment that have been contaminated can all transfer the bacteria to fruits and vegetables still in the field. In recent years, it has been discovered that consuming unpasteurized (or raw) milk and milk products, as well as unpasteurized apple juice and cider, may also be a cause of E. coli O157:H7 infection.

Finally, coming into contact with the feces (i.e., stool) of an infected person or with cattle or handling other farm animals (such as at petting zoos) are additional mechanisms in which infection may be transmitted.

Why it is an important food safety issue; its relative importance as compared to other food pathogens

There are a number of compelling reasons for treating E. coli O157:H7 contamination as a serious food safety issue:

Easily confused with other diseases or conditions – the early symptoms of E. coli O157:H7 infection are not unique to the bacteria. Nausea, diarrhea and stomach cramps are often attributed to other conditions. This misdiagnosis has been known to lead to inappropriate use of antibiotics, which can actually have a deleterious effect on the condition.

Potentially fatal – depending on the vulnerability of the victim's immune system, outcomes of the infection can range from serious illness to death.

Resilient – the bacteria are capable of surviving several months, if appropriate conditions are in place.

A small dose is all that is needed – it takes very few bacteria to cause infection.

Rapid growth – the bacteria replicate extremely rapidly, establishing and progressing quickly in the victim's system. This makes early diagnosis all the more critical.

The unusual virulence and resilience of E. coli O157:H7, and its potential deadly effect on the body, pose far greater challenges to the food safety system than other food pathogens. While other foodborne illnesses can be addressed adequately by traditional means, E. coli O157:H7's low infectious dose and its potential severity mean that the most effective approach is to ensure all steps are taken to significantly reduce or eliminate its presence.

Current morbidity and mortality rates

The Public Health Agency of Canada (PHAC) reports that 1.39 Canadians in 100,000 were infected with E. coli O157:H7 in 2012 – or some 458 individuals. While this number may appear low, given that Canada's surveillance and tracking system relies solely on patients reporting their symptoms to a health practitioner to be captured in the data, the actual number of infections is speculated to be considerably higher. For every case reported by a patient to a doctor, an estimate of between ten and 47 cases go unreported. Even applying a conservative estimate of ten unreported cases for every captured one, roughly 4,600 Canadians suffer the effects of E. coli O157:H7 infection each year, at a significant cost to the health care system.

PHAC also reports that between five and ten per cent of those who become ill as a result of E. coli O157:H7, as well as approximately 15 per cent of young children and the elderly, will develop the potentially fatal hemolytic uremic syndrome – or HUS.

The following table, published by PHAC, reflects the death rate statistics in Canada of E. coli O157:H7 over the five-year period between 2000 and 2004. The information is gathered by two leading sources – the Canadian Institute for Health Information (CIHI), and Statistics Canada's Vital Statistics. The table shows a minor variance between the two databases: CIHI has a total number of deaths at 18, while Statistics Canada's database shows a total of 14 fatalities over the five years in question. (Statistics Canada's database limits the number of deaths to only those for which these organisms were the principal cause of death.)

Deaths associated with Pathogenic E. coli infection, 2000 to 2004 CIHI and Vital Statistics (Statistics Canada)
  CIHI Database Vital Statistics Database
  Year Number of Deaths (CIHI) Death rate (per 1000 hospitalized with illness) Number of Deaths (Vital Stats)1 Death Rate (per 1000 cases)2
Pathogenic E. coli 2000 5 8.24 6 1.99
2001 2 4.51 1 0.75
2002 6 15.67 3 2.41
2003 1 4.26 2 1.85
2004 4 12.50 2 1.82
Total 18 8.55 14 1.80

1. Deaths in the Vital Statistics database include only those for which these organisms were the principle cause of death.

2. Calculated as the number of deaths in Vital Stats/number of reports in the National Notifiable Disease Reporting system (NDRS).

Trend over past decade in Canada

The good news is that E. coli O157:H7 infections have been declining over the past decade. PHAC is responsible for tracking these infections; and medical laboratories that test patient blood samples report weekly to the Agency's National Enteric Surveillance Program any E. coli STEC cases confirmed through testing.

The following table, published by PHAC and reproduced here, tracks the number of reported cases in the country over the ten-year period of 2002 to 2011. Some 3.8 people in 100,000 were infected with E. coli O157:H7 in 2002, and the figure dropped to 1.4 in 100,000 in 2011 – a reduction of almost two thirds over the decade. In fact, with the exception of the waterborne outbreak of E. coli O157:H7 in Walkerton, Ontario in 2000, which took the lives of seven and affected hundreds more, the decline of reported cases goes back to 1995.

Incidence rates of E. coli reported to PHAC through the National Enteric Surveillance Program, 2002 to 2011

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Incidence rates of Escherichia coli reported to Public Health Agency of Canada through the National Enteric Surveillance Program, 2002 to 2011
Incidence rates of E. coli reported to PHAC through the National Enteric Surveillance Program, 2002 to 2011

(Note: Shiga toxin-producing E. coli, more commonly referred to as STEC, produce Shiga toxin. E. coli O157:H7 is the most prevalent of these and considered responsible for causing 90% of cases of STEC illness. Several non-O157:H7 E. coli are responsible for the remaining 10% of STEC illnesses.)

The Public Health Agency of Canada has generated revised estimates of the number of foodborne illnesses in Canada, which are to be published in the peer-reviewed journal Foodborne Pathogens and Diseases. These estimates will replace the 2008 rudimentary estimate of 11 million episodes per year. The revised estimate is 4.0 million episodes of domestically acquired foodborne illness occur each year in Canada. This estimate is more accurate and lower than the 2008 estimate, and is based on better data and methodologies.

Domestically acquired foodborne illness in Canada is now estimated at four million episodes per year. This still represents a substantial burden of illness, with approximately one in eight Canadians getting sick with a food- related illness in Canada each year.

Dr. Greg Taylor, Deputy Chief Public Health Officer
Public Health Agency of Canada
April 29, 2013

Review of the literature and practices

E. coli O157:H7 was first identified as the cause of a foodborne illness outbreak in the United States in 1982; it was ultimately traced to a supply of contaminated ground beef. Ruminants are believed to be natural reservoirs for E. coli O157:H7, which colonize the terminal end of the colon and rectum of the animal. Its affinity for this portion of the ruminant intestinal tract and the lymphoid tissue of the recto-anal junction may lead to high concentrations and prolonged shedding of the organism.

Indeed, the increased presence of the bacteria in beef has been linked to modern production and processing. (Note: prepared foods, dairy products, fruits, nuts and leafy vegetables are also susceptible to contamination; however, this independent review is limited to beef contamination.)

As already mentioned, the trend for foodborne illnesses caused by this bacterium in beef has been on the decline for the past decade and more. The processing industry's efforts to adopt best practices when removing the hide, eviscerating, and decontaminating carcasses have all contributed to this decline.

Today, most of Canada's beef is supplied by only a handful of large processors. In addition to processing their own cattle, processors also slaughter animals that have been raised by various producers. The larger plants process between 2,500 and 4,200 head of cattle a day.

The concentration, confinement, and commingling of so many animals from several different origins causes them increased stress, thus facilitating the spread of the bacteria – whether that environment be in the transport trucks, holding pens, or on the slaughtering floor.

For reasons as yet unknown to researchers, some cattle produce virtually no detectable E. coli O157:H7 in their feces, while others have been found to produce enormous quantities at various times of the year. Referred to as super shedders, these cattle produce higher quantities of the bacteria in the warmer months (the fecal prevalence of E. coli O157:H7 has been shown to be highest in ruminants in summer months, and decreases to low or undetectable levels in winter – suggested by some to be due in part to the associated additional hours of daylight). As mentioned, other animals super shed when they are stressed, such as when confined in small pens with several other animals.

Because this bacterial shedding is cyclical, individual animals do not shed large numbers of bacteria consistently; in fact, there can be significant variability in the amount of shedding by a single animal. The inability to identify these super shedders makes control problematic. In view of this, it is not difficult to see how the bacteria can be introduced into the processing plant.

With these challenges in mind, researchers have identified two distinct phases in the beef process in which to research ways to reduce or eliminate the bacteria.

The first phase begins with the animal's birth and ends with its arrival at the door of the processing plant. This is referred to as the pre-harvest phase. The second phase begins once the animal has entered the plant – referred to as the post-harvest phase.

A considerable body of research has been produced to demonstrate that both phases present opportunities to minimize the risk posed by the bacteria. A great deal of work to eliminate the bacteria from the food chain has been done and remains ongoing. The most successful strategy to reduce risk involves the use of both pre- and post-harvest measures, or interventions.

Pre-harvest interventions

The majority of disease-causing bacteria that can spread at slaughter by cross contamination can be traced back to the cattle on the farm; thus, on-farm intervention strategies are sometimes used to help mitigate risks. Pre-harvest interventions that reduce E. coli 0157:H7 should enhance the effectiveness of post-harvest intervention efforts at the processing plant.

Several pre-harvest interventions used at the farm level have produced variable results in studies. The different strategies to reduce E. coli O157:H7 include:

Exposure reduction

  • biosecurity
  • feed and drinking water hygiene
  • reduced exposure to insects and wildlife
  • improved cleanliness of bedding or pen floor
  • feeding of forage to cattle in the days prior to slaughter (a diet high in grain has been
  • found to encourage growth of the bacteria)
  • dietary supplements (these range from protein to energy and roughage additives)
  • intact rearing groups (keeping animals reared together in the same stable environment)
  • rodent control
  • proper water drainage in areas where cattle are kept

Exclusion strategies

  • E. coli O157:H7 vaccination to reduce shedding and develop herd immunity
  • probiotics to restore the animal's intestinal microbial balance
  • supplementation with competitive exclusion cultures
  • feeding Lactobacillus acidophilus
  • direct anti-pathogen strategies, such as:
    • adding sodium chlorate to water to reduce bacterial load
    • providing antibiotics to out-compete the pathogen and reduce fecal shedding
  • bacteriophages administered just prior to slaughter. These are bacterial viruses that, when administered to the animal, infect and destroy the E. coli O157:H7 (still at the research stage)

Post-harvest interventions

Depending on the individual beef processing plant's policies, experience, and procedures, processors determine their own post-harvest interventions at the plant. Researchers have studied closely a number of these, which include:

  • hide washing (the hide being the main source of carcass contamination during processing)
  • washing carcasses (to rid the carcass of bacteria after de-hiding)
  • trimming procedures (trimming off areas of the carcass where fecal or other contamination is visible)
  • pre-evisceration washing (to eliminate any remaining contamination before removing internal viscera)
  • spraying (applying a lactic acid spray to the carcass to kill bacteria)
  • steam pasteurization (to inactivate any remaining bacteria by applying sufficient steam heat to the carcass)
  • irradiation (exposing beef to high doses of radiation) This process has proven particularly effective in reducing bacterial counts, and there have been renewed calls to allow its use. Despite a long-standing negative public perception about the process, the intervention appears to be gaining favour. The practice is not approved for use in Canada at this time.

CFIA must have oversight of farm practices, including clean water, vaccination, lack of manure tags on animals, phage application; these could be phased in over time, not overnight.

Brent Cator,
Cardinal Meats

Best practices for control

Research and industry experience in recent years have shown that some practices are more effective and/or efficient than others. The following interventions are recognized as best practices.

Pre harvest, these include:

  • on-farm cleanliness
  • provision of clean bedding and drinking water
  • addition of sodium chlorate to drinking water

Most producers and processors apply a number of interventions to contribute to maximizing food safety; this practice is referred to as the "multiple-hurdle approach". E. coli O157:H7 vaccination has shown promise in reducing shedding levels in cattle, thereby also reducing the environmental impact of the bacteria. The vaccine is attracting interest in European Union countries. The United Kingdom afforded BioNiche Life Sciences Inc. (the Canadian manufacturer of the vaccine Econiche) a special treatment certification for the product in

August 2012, until such time as it is evaluated for good manufacturing practices. In April 2013, the Swedish government granted the company the same access to conduct on-farm studies in a number of Swedish cattle herds. Should the initial evaluation of the vaccine work, Sweden intends to migrate the pilot project to a larger, multi-farm study in areas of the country where the bacteria predominate.

Post harvest, these include:

  • washing hide-on carcasses
  • washing skinned carcasses
  • best head removal and evisceration practices
  • trimming and steam/hot water/vacuum cleaning
  • spraying with 5% lactic acid
  • spraying with antimicrobial solutions (e.g., peroxyacetic acid)
  • pasteurizing with steam or hot water
  • proper carcass chilling

Best practice interventions end with the processor. The role for food safety then passes to the secondary processor, distributor, restaurant, grocery store and, ultimately, to the consumer to store, handle, and cook beef properly. Canada's food safety system, described in the next chapter, explains those roles more fully.

4 – Canada's Food Safety System

Ours is recognized as one of the best food safety systems the world over; but it is complex and involves all levels of government, the food-producing and -processing industry, retailers, and... yes, consumers too. Each player has an important and active role if the food safety system is to work effectively.

Dr. John Carsley, Medical Health Officer for Vancouver Coastal Health who, along with Sheila Weatherill and others, investigated the Maple Leaf listeriosis outbreak in 2008, noted at the time,

"In all likelihood, none of the individual elements that contributed to the outbreak was sufficient to have caused it alone, so each part of the food safety system must work together as perfectly as possible."

The Weatherill Report's call in 2009 for a coordinated and sustained effort is just as real today. What follows is a summary of Canada's food safety network as it relates to beef and beef products. The reader who would like more information on the subject is encouraged to read Chapter 4 of the Weatherill Report, which describes this intricate system extensively.

The beef producer

We begin the food safety chain as it relates to beef with the cow-calf producer. Producers have a duty to follow on-farm best practices to reduce the risk of transporting both cattle and bacteria to the processor. This means the producer is responsible for providing clean water and bedding, and reducing external stresses to the animals under his or her care. For several reasons, interventions such as the use of E. coli O157:H7 vaccines, feeding probiotics, and others are not currently widely adopted. It must be stressed that, although the use of a vaccine may help reduce shedding of the agent and lower the risk of E. coli O157:H7 being introduced to the abattoir, the vaccine does not benefit animal health. Any potential benefits accrue to public health. Debate continues about whether this intervention is worthwhile – be it from a public health or a cost-benefit perspective.

The beef producer is not governed by any food safety law, regulation or other requirement. Once the animal has grown to about 400 kilograms, it is sent to a feedlot, finished for market and, eventually, transported to a slaughter plant.

The beef processor

Standards and regulations are developed and enforced for the beef processor, whose operations are closely monitored by government meat inspectors.

If the processor is federally licensed, its operations are governed by federal laws and regulations. Processors that handle in-province beef and sell within its boundaries are governed by Federal Food and Drugs Act and Regulations as well as provincial and territorial regulations.

Whether federally or provincially licensed, the processor is required to ensure that its plant structure and procedures effectively meet all the appropriate requirements, and that it produces beef safe for consumers.

The restaurant, local grocer

The local food distribution chain, retailer and food service outlets are governed by local and/or regional public health regulations. These cover areas such as cleanliness of the environment, safe food handling practices, and appropriate cold storage temperatures.

Food safety is not a competitive issue.

Retail Council of Canada

The consumer

At the end of beef's journey from farm to fork is the consumer, whose responsibility may well be considered the most challenging. The beef processor, restaurant owner, and local grocer are each governed by regulations that, if met, ensure that what the consumer buys is safe. However, the consumer also has a significant responsibility in the safe preparation of foods in the home setting.

When it comes to E. coli O157:H7, undercooking ground beef is found consistently to be the main cause of infection. Cooking foods thoroughly (for example, ground beef must reach an internal temperature of 71°C for at least 15 seconds) is essential. The use of a thermometer is highly recommended to ensure that the required internal temperature has been reached.

In addition to proper cooking, several other good food management practices are also important to protect the consumer from illness:

  • frequent hand washing when handling food – and always between handling meat and other food (to avoid cross-contamination)
  • washing food well
  • keeping meat and meat products separate from other foods and
  • refrigerating ingredients and cooked foods immediately after use

The federal government

The Canadian Food Inspection Agency (CFIA, or Agency) – Ensures that the processing industry meets all federal food safety regulations and laws through inspections. This is carried out by CFIA inspectors, who also verify that plants have controls in place to minimize potential risks.

Inspectors' duties range from observing plant operations, checking for animal disease, reviewing and validating written food safety procedures, and collecting samples for validation of safety from microbiological contamination.

In the event a contamination event is discovered or a foodborne illness outbreak occurs, CFIA launches an investigation into the source. Its objective is to determine which food may be the culprit, and where it has been distributed. CFIA then traces the contaminated food back to the production facility. At this point, federal partners (such as Health Canada and the Public Health Agency of Canada) and, in some cases, provincial partners are engaged in the investigation. Investigation findings are then sent to Health Canada for health risk assessment.

If a food recall proves necessary, in almost all cases it is initiated by the processor, with the support of CFIA. If the processor is either unable or refuses to recall a product voluntarily and Health Canada has confirmed that the product poses a public health risk, CFIA will recommend that the Minister of Agriculture and Agri-Food order a mandatory recall of the food product.

Health Canada (HC) – Responsible for establishing the food safety and nutritional quality standards that are enforced by CFIA, Health Canada also develops educational materials for the public about food safety issues. As noted, it conducts health risk assessments of food when requested by CFIA. Under the legislation governing the Agency (the Canadian Food Inspection Agency Act, 1997), the Minister of Health is responsible for assessing the effectiveness of CFIA's food safety system.

The Public Health Agency of Canada (PHAC) – This player in the federal food safety chain is responsible for the support and coordination of national enteric disease surveillance activities, and for taking a lead role under the Foodborne Illness Outbreak Response Protocol (FIORP) during multi-jurisdictional foodborne illness outbreaks. PHAC also issues health protection advice to the public during such events. Its National Microbiological Laboratory provides additional support to the provincial public health and other laboratories in the investigation of foodborne illness.

Agriculture and Agri-Food Canada (AAFC) – While not a formal partner in the food safety system, this federal department conducts research to support food safety policies.

The Foodborne Illness Outbreak Response Protocol (FIORP) is an agreement among the federal, provincial and territorial governments that identifies the technical and operational procedures each of Canada's food safety authorities are to follow in the event of a national or international foodborne illness outbreak.

The provincial/territorial governments

Provincial/territorial governments govern the operations of beef processors that operate within provincial boundaries only. The laws and regulations within the provinces and territories vary across the country but are usually similar to those of their federal counterparts.

When an outbreak of a foodborne illness occurs, the provincial/territorial health authorities are ordinarily the lead agents for the investigation of and response to the event. If the event crosses provincial boundaries, however, PHAC leads the response, while working with the provincial health authorities.

The local (municipal)/regional public health authorities

Local food processors, food retailers and restaurants are inspected by local or regional public health authorities. Again, the same diversity in the structure of food safety organizations seen at the provincial/territorial level is reflected across the various local/ regional public health inspection organizations. Despite this diversity, their roles are essentially the same: to ensure that what is sold to consumers is safe. In the event they learn of a foodborne illness or outbreak, they are required to report these to their province or territory.

5 – A Summary of Key XL Foods Inc. Recall Events

Below is a summary of the key events of the period spanning September 4, 2012 and January 14, 2013 that relate to the discovery and subsequent handling of contaminated beef produced and distributed by XL Foods Inc. A graphic timeline is available by visiting the Canadian Food Inspection Agency's (CFIA, or Agency) website at:
www.inspection.gc.ca/DAM/DAM-food-aliments/STAGING/images-images/xl_foods_chrono_1351614801630_eng.jpg.

September 4 CFIA receives positive results for E. coli O157:H7 in beef trim sampled at the Ginger Beef Choice Ltd. plant in Calgary, Alberta on August 29. On investigation, officials learn the raw product originates at the Brooks, Alberta plant (Establishment 38) operated by XL Foods Inc. United Stated Department of Agriculture's Food Safety and Inspection Service (USDA FSIS) inspectors also alert the Agency of E. coli O157:H7 in beef trim sampled at the United States border on August 30. CFIA launches an investigation to determine whether any beef has reached the Canadian marketplace. CFIA asks Health Canada (HC) to carry out a Health Risk Assessment (HRA). At this point, the FSIS enhances its oversight and testing of products originating from the XL Foods Inc. plant.

September 5 CFIA issues a Corrective Action Request (CAR) to the Ginger Beef Choice Ltd. plant.

September 6 Having ascertained the affected beef originates from XL Foods Inc.'s Brooks plant, CFIA verbally asks XL Foods Inc. for distribution information and test results for beef processed on August 24 and 28.

September 7 CFIA issues a CAR to XL Foods Inc. for a Point of Entry violation. The Agency now formally requests distribution and other information by no later than September 8. CFIA informs the Public Health Agency of Canada (PHAC) of positive E. coli O157:H7 findings and that DNA fingerprinting of the bacteria is under way.

September 8 and 9 CFIA inspectors monitor that XL Foods Inc. is developing a response (Corrective Action Plan [CAP]) to address the CAR issued on September 7.

September 10 XL Foods Inc. begins to provide distribution and sampling information to CFIA over the next two days. CFIA adds September 5 to August 24 and 28 production dates for further review.

September 11 FSIS reports two additional presumptive positive samples in beef originating from XL Foods Inc. beef that was tested on September 7 at the border. CFIA inspectors begin to monitor de-hiding area and sanitation practices for their potential to contaminate.

September 12 FSIS confirms the two positive samples. Product is destroyed. No product has been distributed in Canada. CFIA mobilizes an in-depth review team over the next eight-day period to evaluate meat, food safety and science aspects of the plant's operations.

September 13 DNA results match two illnesses in Canada, along with samples tested at the United States border on August 30. XL Foods Inc. is removed from list of establishments eligible to export to the United States.

September 14 The CFIA team completes review and reports that XL Foods Inc. must improve its trend analysis on high event days (periods when positive sampling tests are higher than normal) and follow documented procedures.

September 15 XL Foods Inc. issues voluntary recall notice to customers for August 24, 28 and September 5 production dates.

September 16 CFIA issues a Health Hazard Alert (HAA), warning of products affected by the voluntary recall. The Agency continues to assess whether other production dates are affected.

September 17 CFIA activates the National Emergency Operations Centre to help coordinate response activities. It issues another HHA for additional products tied to the three dates.

September 18 CFIA issues six more CARs to the company to address issues identified by the in-depth review team. XL Foods Inc. makes its first contact with the Retail Council of Canada to discuss the recall. More HHAs are issued. Alberta Health Services (AHS) launches an investigation into an outbreak of three cases of E. coli O157:H7 that appear to be associated with mechanically tenderized beef purchased from the same Costco location. A fourth case is identified later in the day.

September 19 CFIA issues another HHA identifying products from secondary processors derived from the recalled beef. The Agency requests more information from XL Foods Inc. for six high event dates (the recalled dates plus August 27, 29 and September 8). XL Foods Inc. provides CAPs for two CARs and expands its voluntary recall to include beef produced on second shift of September 5. CFIA continues to communicate with the FSIS daily.

September 20 CFIA issues another HHA identifying products from secondary processors derived from the recalled beef. The company provides information requested by the Agency on the 19th. The Province of Alberta activates its Foodborne Illness Response Team. Six clinical illnesses under investigation are not linked at this time to any of the recalled products.

September 21 CFIA identifies two additional production dates at risk for contamination (August 27 and 29). FSIS also determines that these are "at risk" dates, based on their data analysis. XL Foods Inc. initiates recalls for these dates (affecting both Canadian and United States customers). AHS confirms that a Calgary case of illness is associated with product purchased at a Safeway store.

September 22 CFIA issues another HHA identifying products from secondary processors derived from beef produced on August 27 and 29. XL Foods Inc. contacts its customers about the expanded recall.

September 24 FSIS notifies CFIA of positive E. coli O157:H7 sample from boxed beef in California, produced by XL Foods Inc. on August 27.

September 25 CFIA issues another HHA, identifying products from secondary processors derived from beef produced on August 27 and 29. The Agency updates other food safety partners and industry on the recall event, and submits a letter to the editor to two Calgary newspapers. CFIA requests a health opinion from HC regarding primals, sub-primals, etc. from recall dates. (A primal is a cut of meat initially separated from the carcass during processing. A sub-primal is cut from the primal, and is larger than a steak, roast, or other single cut.) HC provides the Agency with its HRA on the Edmonton Costco store's tenderized beef products.

September 26 PHAC and AHS link the human illnesses to steaks from Costco. Costco issues a recall notice for steaks sold at its Edmonton store. The source and time of contamination of all products remains unconfirmed. XL Foods Inc. submits CAPs for outstanding corrective action requests by the Agency. It agrees to issue a recall of products from its US accounts. At the request of AHS, PHAC activates the Outbreak Investigation Coordination Committee (OICC). Japan (an importer of XL Foods Inc. products) enquires into the recall incident.

September 27 XL Foods Inc. recalls all edible meat from the August 24, 27, 28, 29 and September 5 production dates. It submits CAPs for five CARs; CFIA reviews these and finds them unacceptable. The Agency temporarily suspends XL Foods Inc.'s licence to operate the plant, having determined that the company was not implementing sufficient food safety controls. The company has neither applied needed corrective actions nor supplied acceptable and sustainable plans to address longer term issues. All products at the plant are to be detained until tested negative. CFIA issues another HHA. Mexico delists the plant as a precautionary measure. CFIA prepares letter to Mexican government notifying them that none of the implicated product was exported to Mexico.

September 28 OICC concludes that the four confirmed illnesses originate from contaminated beef produced at the XL Foods Inc. plant. The company submits revised CAPs for the five most recent CARs. CFIA informs the company by letter of the requirements that it must meet to regain its licence to operate the plant. CFIA issues two HHAs, which now include whole muscle cuts (in addition to ground beef products). FSIS expands its Public Health Alert to include all cuts from the affected dates (roasts, steaks, etc.). AHS requests Costco to cease mechanically tenderizing beef at all of its Alberta stores.

September 29 CFIA accepts company's proposed CAPs, which are implemented under a specially assigned CFIA CAP team. The Agency finalizes an enhanced trend analysis monitoring plan, as well as an additional layer of sampling and testing of the company's product, which is implemented by a second CFIA team. More HHAs are issued, still tied to the five production dates in question.

September 30 CFIA begins to sample all carcasses in storage at the plant, where they will remain under detention. The Alberta Premier holds a press conference, confirming nine cases of E. coli O157:H7 illness in Alberta. Four are associated with Costco, while the others remain under investigation to establish the source.

October 1 Carcass sampling continues at the plant. A PHAC Public Health Notice informs the public about risks of infection and ways to ensure food safety. CFIA has a discussion with Canadian Restaurant and Food Service Association on the recall, and updates the Retail Council of Canada. CFIA issues another HHA.

October 2 XL Foods Inc. decides to divert all boxed meat products in inventory to cooking or rendering. Product recall tracing through secondary and tertiary distributors, manufacturers and retailers continues. Letters inform Japan, Hong Kong, China, The Philippines, South Korea and Thailand of the recalled products. Response to media enquiries continues.

October 3 The Minister of Agriculture and Agri-Food and CFIA President hold press conference at a Calgary laboratory to respond to questions. Testing of carcasses concludes. Product recall tracing continues. Additional exports to Russia, Egypt, Japan and Hong Kong are identified and these countries are notified by letter. CFIA issues another HHA. Japan requests an investigation report on the incident.

October 4 A second press conference is held. Agency personnel have identified two presumptive positives among some 292 tests to date. CFIA continues its monitoring of the recall process. Hong Kong submits several questions; South Korea has officially banned all plant products until corrective action has been taken; and The Philippines will return all containers shipped by the plant.

October 5 CFIA and PHAC hold a technical briefing with media. OICC notes an additional illness associated with the investigation. Of 445 samples tested, three are presumptive positive. CFIA completes its review of company's CAPs. PHAC announces a new confirmed case in Newfoundland and Labrador. FSIS now estimates that some 1.1 million pounds of trim and approximately 1.4 million pounds of primal and sub-primal cuts used to produce steaks, roasts, mechanically tenderized steaks and roasts, and ground beef were received by United States firms.

October 6 PHAC and CFIA hold another technical briefing for media. Four presumptive positives out of 518 samples are found. PHAC announces a total of 10 confirmed cases of illness.

October 7 As a result of further investigation results, CFIA issues another HHA. Included are raw and ready-to-eat products.

October 8 CFIA and PHAC hold another technical briefing for media. CFIA will begin a detailed assessment of the plant to determine if the facility has successfully resolved issues uncovered by the Agency's in-depth review team. PHAC announces 11 confirmed cases of illness.

October 9 CFIA conducts its assessment of the plant. Singapore has reported it will remove all XL Foods Inc. products from retail.

October 10 CFIA reviews results of assessment. PHAC announces 12 confirmed cases of illness. CFIA issues another HHA.

October 11 CFIA and PHAC hold another technical briefing for media. CFIA announces that XL Foods Inc. will move to next stage in review process. Agency officials will closely monitor plant's processing of carcasses.

October 12 CFIA monitoring continues, and products remain under detention. The Agency issues another HHA. PHAC announces 15 confirmed cases of illness.

October 13 XL Foods Inc. lays off 2000 staff. The Minister issues a statement in response. CFIA continues to closely monitor plant operations, and takes samples from primal meat cuts for E. coli O157:H7 testing.

October 14 and 15 CFIA allows some inedible products under detention to be rendered. None of the material will enter the food system. The company reinstates 800 staff, and begins to train them on new food safety procedures.

October 16 Plant cuts last remaining carcasses under supervision, and the CFIA continues to test samples. More trailers of inedible meat are dispatched for rendering. CFIA issues another HHA.

October 17 CFIA announces it has completed its review of the plant's E. coli O157:H7 controls and begins an assessment. The company requests that all 12 million pounds of recalled beef products go to land-fills in Alberta.

October 18 JBS USA announces it will immediately take over the management of XL Foods Inc. operations at the Brooks plant. The agreement provides JBS with the exclusive option to purchase the Canadian and United States operations of XL Foods Inc.

October 19 Test results for carcasses processed between October 12 and 17 are negative for E. coli. CFIA holds a technical briefing and issues a statement. OICC confirms an additional illness linked to XL Foods Inc. investigation. PHAC confirms 16 cases.

October 20 Inedible products continue to be rendered. CFIA issues another HHA.

October 21 and 22 Inedible products continue to be rendered. Meat not part of the recall but stored at the plant is moved to a federal facility, and will be cooked at a high temperature to destroy any traces of E. coli O157:H7.

October 23 CFIA holds a technical briefing and announces that XL Foods Inc.'s Brooks, Alberta plant is permitted to resume operations under enhanced CFIA oversight. Products captured by the recall continue to move from the plant for rendering or landfill disposal.

January 14, 2013 Normal operations resume at the Brooks plant under the new ownership of JBS Food Canada Inc. CFIA samples consistently test negative and all outstanding CARs have been addressed.

6 – Key Findings/Gaps

The Panel's mandate was to review the events that led to and followed the outbreak of E. coli O157:H7 at the XL Foods Inc. plant in Brooks, Alberta that made 18 consumers ill and cost the beef industry, our health care system, and consumer confidence dearly.

Below is what we learned in our extensive review of documentation, current literature on the efficacy of pre- and post-harvest interventions, and in-depth interviews with some 65 involved and/or interested key stakeholders.

Before discussing the factors that led to this particular outbreak, we begin with our additional findings about pre- and post-harvest interventions and some of industry's views on their use.

Pre-harvest interventions

Chapter 3 provides a snapshot of the various pre-harvest tools available to beef producers to reduce the presence of E. coli O157:H7 in the cattle they raise. Each intervention demonstrates a degree of efficacy when used on its own, although none is known to be 100% effective in eliminating the bacteria.

There is a Canadian-made E. coli O157:H7 vaccine that shows promise in reducing bacterial numbers in shedders and helping to reduce the E. coli O157:H7 burden from animals entering a processing establishment. Our immediate question when we learned this may well be echoed by the reader of this report: "Why not vaccinate all cattle and be done with it?" Another simple question – with a not-so-simple answer.

If we found a pre-harvest intervention that worked, we'd consider it. However, we still need to operate to the .0001% standard going out the door, so any pre- harvest tool that only drops our load 30% doesn't change our effort.

Dr. Angie Siemens,
Cargill Meat Solutions

Vaccinating cattle is expensive, time-consuming, sometimes a dangerous practice (unlike their dairy counterparts, beef cattle are unaccustomed to being handled), and stressful for the animal. Moreover, the bacteria pose no risk to animal health; rather, an animal that is free of E. coli O157:H7 only benefits human health. Because the next player in the beef supply chain – the processor – is required by law to have procedures in place to ensure the product leaving the plant is safe for consumers, the general attitude of cattle producers is that the intervention is not worth the trouble and expense.

Similarly, most of the processors we spoke to do not see the need for pre-harvest interventions for two reasons: the price they would pay per animal would be higher to cover the producer's vaccine costs, and processors are confident that their post-harvest interventions are effective in helping to ensure a safe end product. In the view of the processors, vaccination is not cost effective.

You can't inspect food safety into the product.

Canadian Meat Council

Pre-harvest interventions do, however, have their advocates in the industry. These interventions serve not only to reduce the prevalence of the bacteria in beef cattle, but also have a beneficial environmental impact. A lower E. coli O157:H7 burden in the environment means a lower risk of water and crop contamination. As the pie charts in Chapter 1 of this review show clearly, these are also mechanisms through which consumers may become infected.

Post-harvest interventions

The union representatives of both plant and Agency workers that we interviewed expressed concern about line speed at the XL Foods Inc. Brooks plant.

Employees complained constantly about line speed, especially in the tight spaces at XL Foods. Some of the Corrective Action Requests inspectors tried to initiate included the need to slow down line speed.

Bob Kingston
Public Service Alliance of Canada

They noted that the processing establishment was reluctant to slow down line speed unless absolutely necessary; slim profit margins in the industry mean that higher line speeds need to be maintained to maximize production and profits. If the line speed is too fast, workers would have little time to examine and trim off visible contamination from carcasses before being moved to the next processing station. Staff would also have insufficient time to properly sterilize their knives between trimmings. If sprays are not properly applied to the carcass, they could serve to spread the contamination across a wider area.

These same union representatives told us about high workforce turnover and substantial labour shortages at the Brooks plant – factors that should trigger a slower line speed to allow for adequate inspection by the staff. The company's Quality Assurance Manager confirmed that turnover was some 30% each year at the Brooks plant.

These concerns notwithstanding, the Panel was unable to reach any definitive conclusion about the possible effect of line speed on this contamination event, as hourly line speed details for the days in question were not available to us. CFIA representatives indicated that line speed at XL Foods Inc. was actually slower than that at comparable US plants. Line speed is a management tool that can be used to ensure food safety. Indeed, we were also informed that plant inspectors stopped the production line 39 times between January and September 2012 to address food safety issues.

Hourly line speeds should be adjusted to accommodate prevailing circumstances; for example, if there are excessively dirty cattle presented to slaughter, line speeds should be reduced appropriately to allow for removal of visual contamination. Although the Panel had access to the average number of cattle slaughtered daily for the months of August and September, this provides no indication of hourly fluctuations.

Circumstances that led to the contamination

If the CVS had been applied properly and regular inspections were in place, the problem should not have happened.

Bob Kingston
Public Service Alliance of Canada

We were asked to determine how the event occurred. What follows is what we believe are the key factors that led to the beef contamination, how we view the food safety programs and inspection policies and protocols, the effectiveness of communication between XL Foods Inc. and the Canadian Food Inspection Agency (CFIA, or Agency), and whether either could have detected the contamination before beef had left the plant for distribution and commerce.

No sign of trend analysis

XL Foods Inc. tests its beef products at regular intervals throughout each of two shifts daily, in accordance with federal regulations. Test results are supposed to be reviewed to determine any trend, indicating increased contamination.

High event period days were not as high on the agenda as they should have been.

CFIA

Sampling spreadsheets studied by the Panel show high event periods (HEPs) very clearly. We found no indication that the company was identifying and analyzing those results for trends during the time leading up to the identification of the E. coli O157:H7 contamination; consequently, it was unable to make any efforts to establish and correct the root cause of the problem.

HEPs are characterized by positive test results for E. coli O157:H7 exceeding a predetermined threshold, and they require priority attention.

When a trend in positive results is detected, the plant is expected to investigate the reason, notify CFIA inspectors, and propose corrective actions, including what will be done with untested product. For their part, inspectors are expected to check test results from time to time to verify that the plant's food safety controls are working. Indeed, the Panel reviewed sampling data as far back as January 2012, and noted a number of HEPs that should have resulted in root cause analyses by XL Foods Inc., but we have no evidence to suggest any analysis actually occurred. The company had established action limits at <10%, >10%, <20% and >20%, but there was no indication of how the action limits were linked to the sampling program.

The CFIA in-depth review team identified non-compliance associated with a HEP day as far back as December of 2011. Although 40.9% of samples from all pre-grind raw materials produced on December 21, 2011 were presumptive positive for E. coli O157:H7, actions taken by XL Foods Inc. were inconsistent with the company's guidance decision document. The latter document instructed the actions to be taken when positives exceed 20% in a single production day. Products from an entire shift were released with no further action. There is no documentation to indicate that CFIA inspectors were notified of this. The Panel is concerned, however, that this non-compliance was not identified much earlier. In our view, this is indicative of long-standing problems at XL Foods Inc.

While the United States Department of Agriculture's Food Safety and Inspection Service (USDA FSIS) recommends companies use a threshold of 5% positive tests without having to take corrective action, it does allow establishments to set their own HEP criteria. Similarly, processors in Canada can establish their own threshold in their respective HACCP plans, under the guidance of CFIA. XL Foods Inc.'s food safety plan set its bar for a HEP at 10%. Yet, on two consecutive days in the last week of August (the 27th and 28th), E. coli O157:H7 was found in over 11% and just below 9% of samples tested, respectively. The company took no apparent action to determine the root cause of the first of these trends at the very least.

In fact, the Brooks plant experienced a similar HEP in March 2012, when trim test results reached 12.33%.

This same inappropriate response after a HEP also occurred in the Listeria outbreak of 2008, involving Maple Leaf Foods.

Non-implementation of bracketing policy

Secondly and equally importantly, XL Foods Inc. was not applying its own Food Safety Enhancement Program (FSEP) procedures and implementing its bracketing protocol. The company's guidance document had not been updated since 2009; it describes bracketing of products, but bracketing is neither defined clearly nor always followed.

CFIA inspectors can ask the plant for their trend analysis, but their tools for examining results closely are limited.

CFIA

The latter procedure is triggered when HEPs are detected, and involves identifying and isolating containers processed immediately before and after the positive-tested batch with the higher results (i.e., >/=5% positive). All of these products are then tested and disposed of, according to test results. If they are positive, the beef is cooked, rendered to destroy the bacteria, or sent to the landfill.

XL's E. coli problem didn't happen overnight; there was a lead-up to this happening. Tests were not being done properly.

Doug O'Halloran
United Food and Commercial
Workers

Because test results were not being analyzed, potentially contaminated beef was not bracketed and, as a result, likely found its way out of the plant. Given this lack of bracketing, once the contamination was investigated, all products from the dates of contamination had to be added to the list of recalled products.

For its part, CFIA was clearly not monitoring the company's FSEP and identifying deficiencies as carefully as they should have been.

Food safety programs

An effective food safety program depends on ongoing processes that involve all levels of an organization. It requires a philosophy of and commitment to monitoring, verifying, and validating – all of which contribute to a process of continuous improvement. Food safety is a journey, not a destination.

The company implemented a revised food safety plan in 2009, but the Panel saw no evidence that the company had conducted any further review or made any changes or improvements to it since that time.

As an example of the value of continuous improvement to food safety, the XL Foods Inc. plant was using the N60 sampling protocol at the time of the event but was not using the latest methodology (which uses the N60+ sampler) and so was less likely to detect contamination. XL Foods Inc. adopted the N60+ sampler when it reopened its doors in October. Had the company been vigilant about continuous improvement, it would have adopted the more effective N60+ sampler earlier.

Once the E. coli O157:H7 contamination event was detected, the CFIA in-depth review team issued a Corrective Action Request (CAR) to XL Foods Inc., requesting the company improve the way it manages pathogens at the plant. The team found that systems were in place, but were either not being implemented fully or updated on a regular basis.

Inspectors are still being told in some areas to focus on their own job and not to point out concerns outside their area of work.

Bob Kingston
Public Service Alliance of Canada

XL Foods Inc.'s recordkeeping of monitoring activities and its validation of procedures and equipment maintenance were found to be deficient. In addition, sampling techniques were inconsistent. These shortcomings should have been identified by CFIA inspectors before the contamination event occurred.

The Compliance Verification System (CVS) tool is meant to be used by inspectors and ensures that they consistently and fairly verify a plant's compliance with regulatory requirements. There was no evidence to substantiate that the recall plan was carried out appropriately. The company's Corrective Action Plan (CAP) – its formal response to CFIA's first CAR – contained no component designed to analyze the data, determine the root cause of contamination, and address the sustainability to prevent the CAR from happening again. These action plans are reviewed and approved by CFIA before being implemented.

In addition, XL Foods Inc. was not reviewing its Hazard Analysis and Critical Control Point (HACCP) plan on a regular basis and updating it as necessary.

The company did not conduct mock recalls on an adequate scale. The exercises did not involve CFIA staff at the plant, and were therefore not reviewed by inspectors through the CVS review of tasks. XL Foods Inc. did not conduct full mock recalls and this undoubtedly contributed to plant staff being unprepared to cope with what they later described as a "chaotic" series of requests from CFIA.

A single E. coli O157:H7 clone was found on a number of different production dates. The same clone was subsequently identified in products sampled in each of the affected consumers' homes. Indeed, the clone was also found in samples taken from infected patients. Further, the Panel determined in the course of our review that primals in California found to be contaminated and traced back to XL Foods Inc. were also the same genotype.

Finding the identical clone in several samples over a period of days is highly unusual, and suggests strongly a point source, such as a piece of equipment within the plant. As beef came in contact with the source, it also became contaminated, and the nightly cleaning procedures were apparently inadequate at eliminating the bacteria.

The solution is not for CFIA to hire more inspectors; rather, we must make better use of the ones we have.

CFIA

As many as four samples tested positive in the early days of this outbreak (three by FSIS and one by CFIA at the Ginger Beef Choice plant) – all of which came from the Brooks plant, and all of which XL Foods Inc.'s laboratory (IEH Laboratories and Consulting Group) did not detect. As noted above, it may have been poor sampling technique that allowed this to occur.

The production dates of the first two positives (those taken at the Ginger Beef Choice plant and by FSIS officials at the border) could not be established immediately, because XL Foods Inc.'s product labelling did not provide useful information which is required by CFIA. This caused unnecessary delays in establishing a link between the two positives that could have helped the company and CFIA make important decisions about what to do with related product.

Audits of some 20 Canadian processing plants by USDA's FSIS in 2007 and 2009 identified deficiencies in pre-operational sanitation and implementation of HACCP requirements in the vast majority of these establishments. The same deficiencies were detected by CFIA's in-depth review team at the Brooks plant and may suggest a generalized problem in the processing industry. That said, FSIS found that CFIA's inspection of and enforcement actions in relation to these same procedures were also lacking. FSIS's most recent audit (Fall 2012) has not yet been received by the CFIA. It is noteworthy, however, that CFIA audits conducted on US plants often reveal similar deficiencies.

Inspection policies and protocols

Despite applying the CVS tool, CFIA inspectors did not observe that XL Foods Inc. was not following its own food safety plan.

Having more inspectors isn't all that is needed, though. Inspectors must enforce what they see.

Doug O'Halloran
United Food and Commercial
Workers

CFIA mobilized three in-depth review teams to the plant in the days following the contamination event to identify deficiencies: in meat, food safety, and science. The first two were deployed to the plant, and the third to the nearby IEH laboratory. At the plant, the meat and food safety teams noted that the carcass pasteurizer stationed in the primary carcass wash area was not functioning at full capacity and 12 of its 100 water nozzles were clogged; this indicates the water filtration system was not functioning well. The Panel feels it is fair to ask why this problem had escaped the prior notice of CFIA staff at the plant, as well as XL Foods Inc.'s Maintenance Prerequisite Program.

An extra non-food safety station was added specifically to ensure product destined for Japan contained no spinal cord remnants and met the less than 20 months age specification. A memo issued on a number of occasions by the CFIA supervisor instructed inspectors that, "unless it's beef destined for Japan, line must not slow or stop unless an emergency; ignore ingesta and other visible contamination and it will be caught later on down the line..." This memo, posted at the relevant inspection station, was visible to both inspectors and plant staff alike. Although the station was added strictly to deal with a trade issue, the memo may, nonetheless, have conveyed the message that food safety was of secondary importance.

Competency training for inspectors

The Panel noted that CFIA's Learning Statistics in the Report of the Operations Branch for 2011-12 reflected a 34% decrease from the previous year in the Branch's investment for learning in the Western Region, while it increased in all other regions. On further consultation with the Vice President of Operations, however, we learned that a pilot program is under way in that region to help improve inspector training at a reduced cost. This may represent improved efficiencies in training programs and account for the decreased costs.

Information exchange

The Panel heard from an official of the union representing line workers (the United Food and Commercial Workers) about a culture and attitude on the part of both CFIA and the plant that discouraged plant and regulatory staff from bringing forward food safety issues that came to their attention. The Panel had no means to validate or refute these allegations, but CFIA pointed out that the line had, in fact, been stopped 39 times between January and September 2012.

It is the union's view that food safety standards and protocols are not being enforced. Among other examples, the official noted smocks were not changed regularly and mesh gloves were not always washed thoroughly.

The union representing government inspectors (the Public Service Alliance of Canada) believes that there are inadequate human resources for the work and would like to see an audit conducted to settle the issue. The Panel was told by a union official that supervisors discouraged inspectors from issuing Corrective Action Requests. In our discussions with CFIA, the Panel was told that the Agency was addressing this issue and both unions mentioned that the situation was improving.

Could contamination have been detected sooner?

It is the Panel's view that, had XL Foods Inc. analyzed its E. coli O157:H7 sampling data and responded appropriately to HEPs in late August, the contaminated shipments would likely have been contained and not left the plant.

Secondly, a robust and well-managed FSEP may have prevented the contamination problem by ensuring an effective sanitation program and well-managed recall system.

Lastly, the time the company took to submit requested information allowed considerably more contaminated product to enter the marketplace than should have been the case. This led ultimately to the need to expand the recall several times.

Effectiveness of response by XL Foods Inc., CFIA and food safety partners

In addition to examining the events that led to the contamination, the Panel was tasked with assessing the response to the contamination by XL Foods Inc., CFIA, and its food safety partners.

Initial detection and investigation

On September 4, CFIA received confirmation of E. coli O157:H7 in beef trim that staff had sampled on August 29 at the Ginger Beef Choice Ltd. plant in Calgary. Officials launched a food safety investigation at the plant and established that the raw product came from the Brooks plant operated by XL Foods Inc.

When you self regulate, you cut corners.

Doug O'Halloran
United Food and Commercial
Workers

CFIA asked Health Canada (HC) to carry out a Health Risk Assessment. CFIA officials followed up at the Brooks plant. (The following day, HC would report no health risk associated with the Ginger Beef plant's product as no product was in distribution.)

Still on September 4, FSIS inspectors alerted the Agency of E. coli O157:H7 in XL Foods Inc. beef trim they had sampled on August 30 at the US border. Because the affected shipment had been detained at the border and remained intact, CFIA determined that none of the product had been distributed in Canada.

Delays

Once the investigation at Brooks was launched by CFIA, six critical days elapsed before XL Foods Inc. provided Agency staff useful information on distribution of product and product identification.

The information first handed to CFIA was coded and could therefore not be acted upon by the regulator; product distribution information was kept at the company's corporate offices off site, which was slow to arrive at the plant. The company did not follow the recall section of the FSEP Manual, which would have made the retrieval of records timely. During this lost time, contaminated product continued to be sold and eaten, unnecessarily exposing additional consumers to a potentially serious health risk.

CFIA staff at the plant made their initial request for information verbally and this may not have conveyed a sense of urgency. It may also have left what was being requested more open to interpretation by the company. Even after the regulator formalized its request in writing the following day, CFIA staff repeatedly extended deadlines for receiving the required data. Each day that passed before contaminated products were recalled allowed them to make their way further along the supply chain and into consumers' food baskets.

This challenging situation was further exacerbated by CFIA's many non-prioritized information requests. The XL Foods Inc.'s Quality Assurance Manager may have been unsure about which request was the most pressing, or was overwhelmed with the volume of information requested. It appears that he did not establish a team to assist with the work, and was determined to address these requests singlehandedly while continuing to perform his regular duties.

The Agency did not coordinate its various requests through a single CFIA official. Consequently, the plant contact received similar requests from different individuals within the CFIA, including the Office of Food Safety and Recall (OFSR) recall coordinator, who also needed this information. In fairness to the Agency, a number of these were repeated requests for information that XL Foods Inc. continued not to provide.

For its part, the company's many attempts at the corporate level to communicate directly with several different senior CFIA officials, as well as the Minister's office, proved disruptive and hindered the process overall.

Actions taken in Canadian- and US-bound product

On September 13, CFIA suspended XL Foods Inc.'s eligibility to ship product to the US as the result of a Point of Entry violation. The Agency continued to allow product destined for the Canadian market to be processed and distributed. As product tested positive had not gone into distribution, there was no evidence to warrant recall of product in distribution in either country.

FSIS reported another positive result on September 24 (in a California store) found in boxed beef originating from the Brooks plant. Because the bacteria was found in primal cuts of beef (an unusual occurrence), XL Foods Inc. expanded its recall to include whole muscle cuts on September 27 for primal cuts from the affected recall dates (August 24, 27-29, and September 5). The following day (September 28), FSIS expanded its own Public Health Alert to include all beef products (steaks, roasts, etc.) from the days under recall.

Mechanically tenderized beef

On September 18, Alberta Health was made aware by Alberta Health Services (AHS) of four cases of illness traced back to mechanically tenderized beef (MTB) at one Edmonton Costco store. Once notified by Alberta Health Services, Costco took immediate steps to cease this practice at that location. On September 28, AHS requested that the store cease mechanically tenderizing beef at all Alberta store locations.

Costco was reluctant to broaden the moratorium on MTB for two reasons. It had already initiated its own recall of beef products that was broader than the questionable production dates. Moreover, it had been tenderizing steaks since 1989 with no food safety issues ever arising from this practice. Following a discussion with the provincial Chief Medical Officer of Health, it agreed to suspend its in-store tenderizing practices across Alberta. Once Costco resumed mechanically tenderizing beef products, it labeled the packaging for MTB products, reminding customers to cook the product fully.

Alberta Health Services was unable to determine if the contamination resulted from the MTB process at Costco or from cross-contamination originating in ground beef also produced at XL Foods Inc. and in the retailer's inventory.

Recall response by XL Foods Inc. and CFIA

The fact that the company did not identify and present a spokesperson reflected poorly on its corporate responsibility, which greatly compounded the problem. The company may have felt it was not producing its own brand and thus had no company brand to protect.

While it did not on the one hand reach out to consumers, senior officials of XL Foods Inc. communicated with a number of their key customers, although not all of them. They emphasized that their decision to recall product was simply to demonstrate their commitment to food safety, despite a strong conviction that the contamination issue was neither significant nor deeply rooted. The Retail Council of Canada felt that XL Foods Inc. continued to downplay the seriousness of the event.

During a high event period, I currently believe that plants should pull primals, in addition to trim, out of the raw processing stream.

Dr. Angie Siemens,
Cargill Meat Solutions

The company extended its recall to include primal cuts, even although CFIA had not asked HC to perform a Health Risk Assessment. The Agency supported the action of the company.

Of several thousands of pounds of detained meat tested by CFIA, only four samples yielded presumptive positive results. CFIA did not impose any conditions on the disposition of the remaining, untainted product. XL Foods Inc. determined that the product was now too old to go to market, electing instead to send it all to landfill.

The Canadian Meat Council (CMC) did not agree with XL Foods Inc.'s eventual decision to extend the recall to whole muscle cuts produced over the five production days.

Indeed, the CMC remains concerned about the prospect of including primal cuts in future recall events, which would add significantly to the amount of product to be cooked, rendered, or sent to landfill. Moreover, it is generally viewed that whole muscle cuts are less prone to contamination than ground products. As the XL Foods Inc. beef recall illustrated clearly, our capacity for cooking, rendering or sending contaminated beef to landfill is inadequate for large quantities of product. The images of thousands of pounds of wasted beef being bulldozed into landfill stunned the public. In addition to the perception of so much wasted product, CMC officials expressed concern that including whole muscle cuts in future beef recalls could well erode consumer confidence in the safety of beef. A strong reminder, in the Panel's view, that developing and adhering to a strong food safety culture is essential to prevent future significant recall events.

Food safety governance and incident management

The Panel noted that, generally, both the food safety governance and management of this incident were sound. Federal departments (CFIA, PHAC, and HC) for the most part demonstrated a good relationship with the Province of Alberta.

However, this could be strengthened further. A communications gap occurred when PHAC released laboratory information on the Saturday of a long weekend without prior consultation with its provincial partner, Alberta Health. Although this was important laboratory information, it had no impact on the outbreak investigation and attracted a great deal of media attention which could easily have waited until Tuesday before release.

Health Hazard Alerts were issued promptly by CFIA; however, the Agency was by its own admission slow to publish other important information. The Panel was told that approval procedures involving three federal organizations often contributed to delays.

Communications with the public

Expanded recalls from the same plant confused the public, heightened concern about food safety in general, and led ultimately to recall fatigue.

CFIA's oft-repeated Health Hazard Alerts (HHAs) left consumers believing the contamination issue was ongoing or growing; again, this only served to diminish public confidence in the food safety system.

The public received what it saw as conflicting information about the number of illnesses caused by the contamination. For its part, PHAC was of the view that only laboratory-confirmed E. coli O157:H7 cases should be reported to the public, while AHS also relied on epidemiological links. This inability of the two organizations to settle quickly on a "case definition" (i.e., epidemiological vs. laboratory data only) also added confusion and could potentially lead to a further loss of confidence in the food safety system.

One retailer recalled a time during the recall when CFIA was instructing consumers to throw out cans of spaghetti sauce that contained ground beef and were perfectly safe, while retailers were attempting to assure customers that these products were in fact safe, because they were fully cooked. This may represent another example of poor communication as CFIA claims they referred only to sauce cooked by consumers that may contain recalled ground beef, not canned product.

Communications with stakeholders

Several key stakeholders in the food supply chain connected with this recall echoed the same frustration. They felt strongly that they were not being treated as partners in the management of the event.

There was miscommunication at the Office of Food Safety and Recall (OFSR) level; Costco was not informed in advance of OFSR's decision to move to a recall of beef sold in one Costco warehouse in Edmonton. The OFSR did not follow proper protocol.

Costco

Although it was diligent about hosting daily calls with retailers, CFIA was reluctant to share information with stakeholders before announcing it publicly.

As a result, participants gleaned little more from these discussions than was already in the public domain. When retailers made specific requests for information, CFIA officials directed them to the Agency's website. Lastly, not all federal food safety partners were represented on the calls; a PHAC official participated sporadically, while no one from Health Canada attended these daily calls. One stakeholder with health-related questions was instructed to submit them in writing and the Agency would convey them to the appropriate official.

Costco demonstrated good corporate responsibility early on by cooperating fully with food safety authorities. Indeed, when XL Foods Inc. contacted store officials to inform them of contaminated ground beef at the United States border, Costco immediately initiated its own recall protocol – some two or three days before the processor's first recall.

The information Costco provided to CFIA was an asset for the recall process, since the retailer was able to respond quickly to CFIA. As a result of their quick response, their membership program and traceability, Costco was disadvantaged by being front and centre in the media.

Costco

Notwithstanding Costco's responsible behaviour, Alberta Health Services publicly released recall information, citing the store name, without alerting the retailer in advance. Costco had no opportunity to alert its customers, who also learned of it in the media. The retailer could have alerted its customers quickly of the impending recall activity, using its accurate membership and purchasing information. CFIA later acknowledged its Office of Food Safety and Recall (OFSR) was responsible for notifying the retailer of the impending announcement, but had not done so. Due to the lateness of the hour and time differences, the Agency had been unable to contact Costco headquarters in advance. The OFSR sent out the HHA and notified Costco HQ the next morning.

Stakeholders such as the Retail Council of Canada (RCC) requested that CFIA at least allow them to listen in on technical briefing calls with the media, so they could convey important information quickly to their clients or members. CFIA did not respond to this request.

The RCC also wanted to reassure customers that retailers were taking their responsibility seriously, and to have confidence in the safety of the products they were buying.

The Agency emphasized its need to confirm all information before releasing it widely. Some retailers noted that even "best guesses" would have been more helpful to them.

Some stakeholders – such as the Canadian Meat Council, Retail Council of Canada, and Canadian Cattlemen's Association – play very direct roles in this type of activity, and they can react quickly and effectively to an event such as a recall if they understand the situation.

In order to act on the information, however, the RCC's issues management teams require complete and accurate notification from CFIA as quickly as possible. They noted that even a few hours' notice would be helpful. Armed with this information, retailers can have product off shelves in as few as one to two hours, thus limiting consumers' exposure to contaminated goods. The RCC does not have a plan to deal with such issues with its own retail members. Similarly, the RCC and CFIA have not developed an action plan to deal with these issues.

In turn, retailers are able to provide CFIA with valuable feedback about how, when, and how much product was removed.

XL Foods Inc.'s underwhelming concern about the issue confused stakeholders. On the one hand, CFIA kept issuing Health Hazard Alerts relating to the expanding recall of beef products; the processor, on the other hand, was downplaying the severity of the situation.

One stakeholder noted its concern about the incremental nature of the recall. Its impression was that the staggered release of information led to a sense of the event being larger than it was.

Still, it must also be recognized that the majority of products are identified for recall early in these efforts, as large food retailers can move products off their shelves rapidly. It may take considerably longer, however, to reach smaller retail outlets and trace the remaining products. Notwithstanding, HHAs are released only if they are needed, and in general identify an increasingly smaller number of affected products.

Stakeholders felt that CFIA should have been more transparent about its reasons for suspending the plant's licence. It was unclear to stakeholders what should be done with beef already processed (i.e., between September 5 and 27, and other dates). There were, however, no regulatory reasons to detain this product.

Beef producers were keen to receive information that would help inform their inventory decisions, such as buying replacement cattle; unfortunately, they received none.

For its part, Costco took a precautionary approach by removing all XL Foods Inc. products processed before the plant closed its doors on September 27.

One stakeholder complained of the absence of a government contact they could turn to for public health information; for an initial period of time, telephone messages went unanswered. Once an official was tasked with responding, however, the feedback proved very helpful.

What went well

The Pulse-Net system, operated by PHAC, provided an efficient and effective forum for laboratory information exchange among all contributing laboratories. This, in turn, allowed for timely tracing back of human illnesses to the contaminated XL Foods Inc. and Costco beef products.

The rapid activation of the National Emergency Response Team (NERT) (comprising key members from organizations in the Western Area and the national headquarters of federal government departments) was a key component of dealing with the event effectively.

CFIA's documentation of the incident was both thorough and well organized.

Despite occasional gaps, communication between provincial and federal public health authorities was generally effective.

The investigation team at Alberta Health Services (AHS) quickly identified the link between human cases and the MTB process at the North Costco store near Edmonton. With the collaboration of company management, AHS staff was able to take rapid action to minimize further exposure of the public to the threat, as well as bring the MTB issue to the attention of CFIA and other provinces and territories.

Communication among CFIA, Health Canada and PHAC was open and constructive.

7 – The Panel's Working Hypothesis of What Happened

While the Panel is unable to provide a definitive version of the specific events as they unfolded, we are able to speculate on what occurred, based on the facts available. This section of our review presents the most probable sequence of events at the Brooks plant.

It is likely that at some point prior to the production dates noted, an animal heavily contaminated with E. coli O157:H7 entered the plant. It may have been a super shedder, releasing large quantities of the pathogen into the environment. Perhaps the carcass was inadequately decontaminated or the numbers of bacteria present simply overwhelmed the processing system. Several best practices and pre-harvest interventions exist that could have minimized the level of contamination reaching the plant; these have already been identified in this review. In our discussions with members of producer associations, we were told that few pre-harvest interventions are used systematically in Canada.

As the contaminated carcass moved through the plant, the bacteria became lodged in or on a piece of equipment within the establishment. The contamination might have been limited only to that day's production had adequate sanitation been performed on this piece of equipment. The Panel learned that inspection of sanitation procedures before plant start-up was done only randomly twice a week. It seems likely that equipment sanitation was inadequate. For example, and as noted within this review, the CFIA in-depth review team quickly identified that 12 of 100 nozzles of the pasteurizer were clogged. The first of several Corrective Action Requests resulting from a Compliance Verification System (CVS) task evaluation on hygiene and maintenance were issued as early as June 2012. It is the Panel's view that equipment maintenance and sanitation were significant problems at the plant.

A unique clone of E. coli O157:H7 identified later strongly suggests a single point source of contamination. As sides of beef continued to pass by this piece of equipment, they were also sporadically contaminated over subsequent production days.

The fact that the company did not pay attention to increasing E. coli O157:H7 positive tests of beef trim had several consequences: it did not identify a high event period (HEP), it did not bracket product adequately, it missed contaminated products, and these then left the establishment. In addition, because plant staff was not reviewing sampling data, the HEP was not identified. Consequently, there was no attempt to determine a root cause, and the contamination continued unchecked until it was picked up outside the plant at Ginger Beef Choice Ltd. and the US border.

In addition, the Panel believes that the sampler used by the plant to test product for contamination may not have been submerged deep enough into the combo (i.e., a large tub filled with beef trim) and possibly missed some of the external contamination of trim. XL Foods Inc.'s Hazard Analysis and Critical Control Point system was neither applied nor managed properly. This is evidenced by the absence of detailed documentation, inconsistent trend analysis, insufficient record keeping on monitoring and validating processes and equipment maintenance, inconsistent sampling, etc. Annual quality verifications of inspection activities (a component of CFIA's Quality Management System) indicated that these were not delivered with scheduled regularity.

Once the E. coli O157:H7 was identified, it was essential to establish the dates of production and quickly determine the distribution of contaminated products. Unfortunately, the information CFIA officials received initially from the company was coded. Further, the key to that code was at the company's corporate headquarters in Edmonton (not at the plant). Much of the information handed over to CFIA officials was in hard copy, so that records had to be searched manually to provide answers to the distribution questions now being requested repeatedly.

The six-day delay in providing this information – while the plant remained in operation and no root cause had been identified – meant that contaminated product continued to be produced and shipped from the plant. Some of this product would go on to be further processed by secondary and even tertiary processors into a variety of beef products, making its identification and distribution even more difficult.

CFIA soon recognized that this had the potential to become a major event and organized an in-depth review team to evaluate all laboratory and plant protocols and procedures. Their investigation revealed several problems, as outlined in this review.

8 – Recommendations of the Panel

Based on the findings laid out in the previous chapters, the Panel has identified several recommendations that we believe will further strengthen the food safety system. They are presented under the themes identified in our Terms of Reference (a copy of which may be found in Appendix I of this report.) A numbered list of these same recommendations may be found at the end of this chapter.

To strengthen prevention strategies and regulatory oversight

1. A strong food safety culture must be developed within the processing plant, and adopted by both plant and Canadian Food Inspection Agency (CFIA, or Agency) staff – at all levels.

The Weatherill Report contained a number of related recommendations: one called on meat processors to accept responsibility for ensuring that food safety is embedded in every level of their business, a second dealt with the need for processors to bring potential food safety issues to Agency staff, and a third called on CFIA to encourage enterprise and accountability among their inspection staff.

To achieve this, the importance of food safety must be a value shared across all levels of the organization as a top priority. All staff whose efforts lead to building a robust culture of food safety should be recognized for those efforts.

CFIA must also foster a strong food safety culture among staff, who must be encouraged to take initiative on potential food safety issues as soon as they are identified.

If plant staff detects issues of possible food safety concern, they must be empowered to report these to a supervisor.

Plant management must also recognize the importance of training their employees on the principles of food safety, as well as providing refresher courses on hygiene, plant sanitation, and related areas that have been identified as problems.

2. There must be a greater emphasis on training and continuing education of CFIA inspection staff.

CFIA should enhance education support for all inspectors in the Compliance Verification System (CVS) and food safety courses, among others, on an ongoing basis.

CFIA should evaluate its methods of training inspectors in food safety to maximize the effectiveness of training, minimize costs, and provide appropriate testing mechanisms to ensure competency.

3. Inspectors should devote proportionately less time to evaluating specimens for pathology and more time training on protocols that have maximum impact on food safety.

To improve the effectiveness of inspectors, CFIA should assess the specific duties their inspectors perform, with a view to evaluating the direct impact of these duties on food safety. More effort should be committed to evaluating trends, and assisting plant staff with root cause analysis when contamination is detected. They should also spend more time evaluating the thoroughness of cleaning and sanitation before shift start-ups.

4. The Minister of Health should assess the effectiveness of the Agency's activities related to its meat program.

The Canadian Food Inspection Agency Act of 1997 s.11. (4) states that "...the Minister of Health is responsible for establishing policies and standards relating to the safety and nutritional quality of food sold in Canada and assessing the effectiveness of the Agency's activities related to food safety."

An assessment of the Agency's meat program has not yet been conducted by the Minister of Health.

5. The CFIA must enforce its oversight responsibilities at the plant.

Examples of these responsibilities include, among several others:

  • Mock recall procedures must be outlined in the processing plant's Food Safety Enhancement Program (FSEP) – already a requirement – and practised regularly with CFIA personnel to ensure the plant is fully prepared in the event of a recall.
  • As also required under FSEP, in the event of a recall, the plant must provide the Agency with distribution records for the recalled products that are complete and in a format that is accessible.
  • Also in accordance with FSEP, the plant must include all of its standard operating procedures and good manufacturing practices in its own food safety plan.

The Weatherill Report recommended that Health Canada fast track approval of technologies that contribute to food safety.

6. CFIA and Health Canada (HC) should continue to expedite the approval of interventions – especially those approved and commonly practised by our food trading partners.

Timely approval of applications for post-harvest interventions (i.e., collaboration between HC and CFIA) will help place our processing industry on a level playing field with our major trading partner – the United States. It is recommended that these interventions be outcome-based rather than prescriptive.

7. Although it has only limited jurisdiction in this area, CFIA should work towards strengthening requirements in the plant's prerequisite plan on the question of purchasing livestock.

This could include, for example, requiring that animals be presented at the plant with a minimum amount of tag, subjected to minimal handling at yards, etc.

8. HC must complete its risk assessment of mechanically tenderized beef (MTB) as quickly as possible, and make known its recommendations concerning the handling of the product.

The federal department issued an open request for scientific data on the issue in December 2012, which ended on January 20, 2013.

9. All major stakeholders (both governments and industry) should work with the academic sector to encourage continued research on pre-harvest interventions that may help reduce the prevalence of E. coli O157:H7 in food animals.

The first opportunity for prevention strategies is at the farm. There is a diversity of views on the range of interventions available – some have been found to be more effective than others. The benefits of effective intervention go well beyond beef food safety Shiga toxin-producing E. coli (such as O157:H7) are also responsible for environmental contamination.

Although human illness associated with E. coli O157:H7 contamination has been shown in recent data to be more frequent in non-meat products, its cause has been traced back to E. coli O157:H7 from animals.

Some of this research may include:

  • understanding the risk factors that contribute to an animal becoming a "super shedder"
  • field studies to determine the efficacy of vaccination to mitigate contamination and HEPs in the processing plant
  • the relative benefits of other potential interventions, such as bacteriophage treatment of live animals and hides, the use of probiotics, adding chlorates to drinking water, and feeding forage only in the days leading up to slaughter

10. CFIA should adopt an initial benchmark of 5% for E. coli O157:H7 in beef trim, at which point inspectors would intensify their inspection activities and evaluate the matter more closely.

The intensified activities could include a complete evaluation of the plant's Hazard Analysis and Critical Control Point (HACCP) plan. The issue of HEPs and bracketing could be addressed under Process Control, as outlined in 3.2.8 of the FSEP Manual.

11. The beef industry should submit a proposal to HC to approve irradiation as an effective food safety intervention. HC should give the application prompt consideration.

While public consultation may be required, substantial research has already been done.

12. CFIA should expand the scope of contaminant testing to include E. coli non-O157:H7 STECs to establish a baseline for its prevalence in beef.

At this time, the incidence of human illness associated with STEC is primarily E. coli O157:H7; however, monitoring E. coli non-O157:H7 STECS will help identify future trends, and assist public health authorities in foodborne illness investigations.

13. CFIA must require that processing plants document the criteria they apply to define a HEP. If a HEP occurs, the plant must perform and submit to CFIA inspectors a root cause analysis. Agency staff must be confident that the plant's proposed corrective actions will mitigate the risk.

It is the Panel's view that, had this been done in the case of XL Foods Inc., the distribution of contaminated product would have been mitigated or avoided.

Plant staff must also share trend analysis reports routinely with CFIA inspectors, and take timely action when a HEP is identified.

14. During the high shedding season for STECs, CFIA must exercise extra vigilance by enhancing the sampling and verification testing used by its inspectors.

There is a clearly demonstrated seasonality associated with E. coli O157:H7 shedding in cattle. The seasons in which there is a higher prevalence of the pathogen should be met with enhanced vigilance.

To strengthen surveillance and trend analysis

15. CFIA should require that data analysis (e.g., trend analysis, process control) be done at a frequency consistent with plant protocols and that, in the event of a HEP, the Agency be notified immediately.

Had this been done in the case of XL Foods Inc., the distribution of contaminated product would have been mitigated or avoided.

16. CFIA inspectors must carry out the range of tasks in the Compliance Verification System (CVS) with the regularity indicated in the tool, to ensure that regulatory compliance processes are working.

The CVS is a recognized and valuable tool for assessing the effectiveness of a plant's food safety control measures but must be applied consistently. Mock recalls are an integral component of control measures; in the case of XL Foods Inc., the company put only minimal effort into this protocol. If CFIA inspectors had used the CVS tool appropriately, they would have directed the plant to take corrective action.

17. CFIA should require that inspectors adjust the frequency and thoroughness of plant sanitation inspections based on their ongoing findings. These evaluations should occur especially before start-up, to ensure that cleaning protocols are adequate.

In the case of XL Foods Inc., inspections were conducted infrequently (randomly twice a week). More frequent inspection would help minimize the risk of contamination due to improperly cleaned equipment. As noted, the Panel believes laboratory identification of the specific genotype of E. coli O157:H7 in this instance points to inadequate cleaning and sanitation of equipment.

To strengthen incident management and recall response

18. CFIA must require that the processor have meat labelling and distribution information at the plant and in an accessible format.

This requirement is already outlined in the FSEP Manual in order to enable the Agency to announce Health Hazard Alerts for contaminated products quickly and accurately. (Although in the case of XL Foods Inc., the label information was at the plant, it was not accessible; the distribution information was not on site.) Every day that critical documentation remained unavailable allowed contaminated product to move further along the food supply chain. Rapidly identifying both the origin of contaminated product and its distribution would have helped to minimize continuing recall expansions.

19. When a recall occurs, CFIA should explain publicly and post on its web site that further recalls may be required once all products from the first production days have been traced through the distribution channels.

This affords the Agency an opportunity to educate the public on how recalls are carried out, as well as what may yet be expected to occur. The diminishing risks relating to extending recalls should also be placed in context (i.e., early recalls will capture the largest amount of potentially contaminated product and thus have the greatest impact on reducing health risks). Providing this additional context to consumers should not only help to prevent recall fatigue, but also promote further confidence in the national food safety system.

20. CFIA should improve the readability of Health Hazard Alerts (HHAs).

HHAs as currently formatted are lengthy, and difficult to understand. They should be more concise and easier to read to enhance their usefulness to consumers.

21. CFIA should ensure that a technical expert is available, along with the national liaison officer for the National Emergency Response Team, to deal with the media and other stakeholders.

The media plays a central role in conveying important information to consumers. The officer must be able to respond to technical questions so the media may paint an entire picture for consumers. In the XL Foods Inc. case, the Agency lost the opportunity to provide the media – and thus, the public – with valuable information about the recall. Risk communication is a valuable skill and the Agency must ensure that those dealing with the media are trained in this discipline.

Several questions from stakeholders went unanswered, either because the national liaison officer did not have the technical expertise to respond, or was unavailable to answer their time-sensitive questions.

22. CFIA should pursue the development of confidentiality agreements with key stakeholders now (before the next recall) to allow for freer and timely exchange of important information.

Major stakeholders can be very effective partners in food safety – particularly in the event of a recall. However, they need information quickly if they are to contribute successfully to the process. Moreover, from a financial perspective, the absence of timely information for industry and other stakeholders, such as the Canadian Cattlemen's Association (CCA) and the Retail Council of Canada (RCC), led to unnecessary delays and financial losses. (CFIA set a precedent for this practice in the Bovine Spongiform Encephalopathy events of 2003.)

23. CFIA should provide press releases under embargo to major stakeholders, and afford them observer status on technical briefings with the media.

It is important that stakeholders be in a position to provide consumers and the media with informed responses. They can only do so if they are themselves informed on a timely basis.

24. During recall events, HC and PHAC officials should attend CFIA's daily conference calls for stakeholders as well as any technical briefings it holds with the media.

A number of stakeholders had specific questions for these federal organizations that often went unanswered since the appropriate officials were not always present.

25. Federal, provincial and territorial health partners must collaborate on a priority basis to develop mutually acceptable definitions, along with messaging to explain them.

There was confusion in the definition of a "case," as well as the use of terms such as "recovered" versus "recovering". In the event of a recall, it is important that the public see that health authorities are in full agreement.

26. If a contamination event results in a recall, CFIA must immediately formalize any requests to the plant in writing for labelling and distribution information on the suspect product. All subsequent requests related to the recall in question should be prioritized and directed to the Plant Recall Coordinator.

A written request emphasizes the urgency of the need for information. To avoid possible confusion, all requests to the plant should be funnelled through a single point of contact (usually the Veterinarian in Charge) and be appropriately prioritized.

To strengthen communication with the public and stakeholders about providing food safety messages

27. Government food safety partners must reach agreement about what they communicate, and who communicates it.

This should be planned in advance of an event for the overall public interest. Partners should reaffirm their commitments to the Foodborne Illness Outbreak Response Protocol.

A major observation in the Listeria outbreak was repeated in the XL Foods Inc. recall: a confused public. Consumers heard conflicting information from government organizations.

28. Federal food safety partners (CFIA, HC, and PHAC) must establish an expedited approval process to address the need for rapid communications during a national foodborne illness outbreak.

The Panel heard from a number of sources that, with the exception of Health Hazard Alerts issued by CFIA, information important to both stakeholders and the public was slow to be released. Consumers' anxiety in scenarios such as a foodborne illness outbreak is best allayed with frequent and clear information. As mentioned elsewhere, closely affected industry stakeholders also needed information to help them make important business decisions.

In national events, such as the XL Foods Inc. recall, this responsibility falls to federal food safety partners (i.e., CFIA and PHAC).

29. PHAC must clearly be seen as the lead in communications with the public during a national foodborne emergency.

These events present valuable opportunities for PHAC to emphasize the role of consumers in food safety, by stressing the importance of handling and cooking meat products correctly to mitigate any risk.

The Weatherill Report also recommended that PHAC lead all communications with the public in any national foodborne emergency.

30. HC should work with the Retail Council of Canada to vigorously pursue opportunities to educate consumers about proper meat handling methods.

These organizations should seize the opportunity to educate consumers about food safety and their important role in it. This could include initiatives such as distributing disposable meat thermometers (or "t-sticks"), and educational brochures at retail meat counters.

Numbered list of recommendations

To strengthen prevention strategies and regulatory oversight

1. A strong food safety culture must be developed within the processing plant, and adopted by both plant and Canadian Food Inspection Agency (CFIA, or Agency) staff – at all levels.

2. There must be a greater emphasis on training and continuing education of CFIA inspection staff.

3. Inspectors should devote proportionately less time to evaluating specimens for pathology and more time training on protocols that have maximum impact on food safety.

4. The Minister of Health should assess the effectiveness of the Agency's activities related to its meat program.

5. The CFIA must enforce its oversight responsibilities at the plant.

6. CFIA and Health Canada (HC) should continue to expedite the approval of interventions – especially those approved and commonly practised by our food trading partners.

7. Although it has only limited jurisdiction in this area, CFIA should work towards strengthening requirements in the plant's prerequisite plan on the question of purchasing livestock.

8. HC must complete its risk assessment of mechanically tenderized beef (MTB) as quickly as possible, and make known its recommendations concerning the handling of the product.

9. All major stakeholders (both governments and industry) should work with the academic sector to encourage continuedresearch on pre-harvest interventions that may help reduce the prevalence of E. coli O157:H7 in food animals.

10. CFIA should adopt an initial benchmark of 5% for E. coli O157:H7 in beef trim, at which point inspectors would intensify their inspection activities and evaluate the matter more closely.

11. The beef industry should submit a proposal to HC to approve irradiation as an effective food safety intervention. HC should give the application prompt consideration.

12. CFIA should expand the scope of contaminant testing to include E. coli non-O157:H7 STECs to establish a baseline for its prevalence in beef.

13. CFIA must require that processing plants document the criteria they apply to define a HEP. If a HEP occurs, the plant must perform and submit to CFIA inspectors a root cause analysis. Agency staff must be confident that the plant's proposed corrective actions will mitigate the risk.

14. During the high shedding season for STECs, CFIA must exercise extra vigilance by enhancing the sampling and verification testing used by its inspectors.

To strengthen surveillance and trend analysis

15. CFIA should require that data analysis (e.g., trend analysis, process control) be done at a frequency consistent with plant protocols and that, in the event of a HEP, the Agency be notified immediately.

16. CFIA inspectors must carry out the range of tasks in the Compliance Verification System (CVS) with the regularity indicated in the tool, to ensure that regulatory compliance processes are working.

17. CFIA should require that inspectors adjust the frequency and thoroughness of plant sanitation inspections based on their ongoing findings. These evaluations should occur especially before start-up, to ensure that cleaning protocols are adequate.

To strengthen incident management and recall response

18. CFIA must require that the processor have meat labelling and distribution information at the plant and in an accessible format.

19. When a recall occurs, CFIA should explain publicly and post on its web site that further recalls may be required once all products from the first production days have been traced through the distribution channels.

20. CFIA should improve the readability of Health Hazard Alerts (HHAs).

21. CFIA should ensure that a technical expert is available, along with the national liaison officer for the National Emergency Response Team, to deal with the media and other stakeholders.

22. CFIA should pursue the development of confidentiality agreements with key stakeholders now (before the next recall) to allow for freer and timely exchange of important information.

23. CFIA should provide press releases under embargo to major stakeholders, and afford them observer status on technical briefings with the media.

24. During recall events, HC and PHAC officials should attend CFIA's daily conference calls for stakeholders as well as any technical briefings it holds with the media.

25. Federal, provincial and territorial health authorities must collaborate on a priority basis to develop mutually acceptable definitions, along with messaging to explain them.

26. If a contamination event results in a recall, CFIA must immediately formalize any requests to the plant in writing for labelling and distribution information on the suspect product. All subsequent requests related to the recall in question should be prioritized and directed to the Plant Recall Coordinator.

To strengthen communication with the public and stakeholders about providing food safety messages

27. Government food safety partners must reach agreement about what they communicate, and who communicates it.

28. Federal food safety partners (CFIA, HC, and PHAC) must establish an expedited approval process to address the need for rapid communications during a national foodborne illness outbreak.

29. PHAC must clearly be seen as the lead in communications with the public during a national foodborne emergency.

30. HC should work with the Retail Council of Canada to vigorously pursue opportunities to educate consumers about proper meat handling methods.

9 – Closing Thoughts

The XL Foods Inc. recall was exacerbated by a number of key factors. The company's recordkeeping was wanting. It was unprepared to deliver important product and distribution information promptly to inspection authorities. Because the recall involved the country's second largest beef processor, producers had few alternatives for their cattle once the plant closed.

Coordination of communications with the public left consumers confused and worried. Over a period of several weeks, they heard that more and more product was not to be consumed. It is no surprise that polls suggest Canadians worry most about E. coli O157:H7 contamination in their food, and believe that it is on the rise.

And it was all preventable.

Food safety is comprised of two essential elements: a system, and the people that implement it.

As we have already noted, Canada's food safety system is a complex one; given the several jurisdictions that govern us, that system necessarily involves many players. Despite some challenges, however, it works. It is recognized globally as a sound approach to food safety. That said, continuous improvement is vital if we are to remain ahead of the food safety curve. The Panel has identified recommendations that we believe contribute to that effort.

The greater element – and the greater challenge – of food safety is people. Systems are of no use without the skill, vigilance and commitment of individuals. The lion's share of our recommendations focus on this element.

We have already noted that food safety is a philosophy. It must be a culture adopted and practised across all levels of an organization – from the company president to the beef trimmer on the night shift; from the veterinarian in charge to the meat inspector. These individuals play a key and important role in the health of consumers. They must take that responsibility seriously.

Appendix I – Terms of Reference of the Independent Expert Advisory Panel

Background

Canada's food safety system is among the best in the world, but events such as the XL Foods Inc. beef recall underscore the need for continuous review and improvement. As a responsible, science-based regulator, the CFIA regularly reviews its policies and procedures to ensure they are aligned with current science and best practices.

In keeping with this practice, the CFIA's Expert Advisory Committee will be supporting a team to conduct a thorough review of events and circumstances related to the XL Foods Inc.E. coli O157:H7 investigation and recall.

Below are the Panel's terms of reference, as they appear in the relevant Orders in Council.

Terms of Reference

Whereas an outbreak of E. coli 0157:H7 occurred in Canada in the fall of 2012, which affected a number of beef products produced by XL Foods Inc., and led to the illness of a number of Canadians; Whereas the Government of Canada wants to take all feasible steps to ensure the safety of the food supply and the health of Canadians, including appointing an Independent Expert Advisory Panel to conduct an independent review into the E. coli outbreak;

And whereas the Governor in Council is of the opinion that it is in the public interest that the mandate of the Independent Expert Advisory Panel, as set out in this Order, be carried out in an expeditious manner;

Therefore, His Excellency the Governor General in Council, on the recommendation of the Prime Minister,

  • (a) pursuant to paragraph 127.1(1)(c) of the Public Service Employment Act, appoints to the position of special adviser to the Minister of Agriculture and Agri- Food, Dr. Ronald Lewis of Abbotsford, British Columbia, as Chair of the Independent Expert Advisory Panel, to hold office during pleasure for a term ending June 7, 2013, and fixes his remuneration as set out in Schedule 1, which per diem is within the range ($1,100 – $1,300);
  • (b) pursuant to paragraph 127.1(1)(c) of the Public Service Employment Act, appoints to the position of special adviser to the Minister of Agriculture and Agri- Food, Dr. Ronald Usborne of London, Ontario, as a member of the Independent Expert Advisory Panel, to hold office during pleasure, for a term ending June 7, 2013, and fixes his remuneration as set out in Schedule 2, which per diem is within the range ($900 – $1,100);
  • (c) pursuant to paragraph 127.1(1)(c) of the Public Service Employment Act, appoints to the position of special adviser to the Minister of Agriculture and Agri- Food, Dr. André Corriveau of Yellowknife, Northwest Territories, as a member of the Independent Expert Advisory Panel, to hold office during pleasure, for a term ending June 7, 2013, and fixes his remuneration as set out in Schedule 3, which per diem is within the range ($900 – $1,100);
  • (d) specifies that the Independent Expert Advisory Panel is to
    • (i) examine the events, circumstances and factors that contributed to the E. coli outbreak in XL Foods Inc. products, including the design, implementation and oversight of food safety preventative control programs, inspection policies and protocols, and information exchange between the Canadian Food Inspection Agency and its food safety system partners, including XL Foods Inc. and foreign regulators;
    • (ii) consider whether the Canadian Food Inspection Agency or XL Foods Inc. could reasonably have detected the contamination prior to beef products entering into distribution and commerce;
    • (iii) review the effectiveness of the response of the Canadian Food Inspection Agency, in light of the additional resources provided to it since 2006 by the Government of Canada, in conjunction with the response of its food safety system partners, including XL Foods Inc. and foreign regulators, to the E. coli outbreak, which review is to include but not be limited to the effectiveness of their prevention, detection, recall response, incident management and investigative activities, as well as their collaboration and communication with one another, the public and stakeholders for the purpose of ensuring consumer safety;
    • (iv) based specifically on the findings and conclusions arising from the matters listed in subparagraphs (i) to (iii), make recommendations, within the existing resources of the Canadian Food Inspection Agency, to strengthen prevention strategies and regulatory oversight, surveillance and trend analysis, incident management and recall response, and communication with the public and stakeholders as it relates to providing food safety messages;
    • (v) perform its duties without expressing any conclusion or recommendation regarding the civil or criminal liability of any person or organization; and
    • (vi) submit to the Minister of Agriculture and Agri-Food, in both official languages, by May 31, 2013, its report on the matters listed in subparagraphs (i) to (iv);
  • (e) specifies that the Chair is to adopt procedures for the expedient and proper conduct of the independent review, including for the review of relevant records and documents and in respect of consultations as appropriate;
  • (f) authorizes the payment, in accordance with Treasury Board policies, of the following expenses incurred in the course of the duties of the Chair and members:
    • (i) travel and living expenses while in travel status in Canada while away from their normal place of residence in accordance with the Treasury Board Travel Directive and Special Travel Authorities;
    • (ii) expenses related to expert staff, as determined by the Chair; and
    • (iii) any other reasonable expenses that, in the opinion of the Chair, are necessary to conduct the independent review.

Appendix II – Biographies

Ronald John Lewis, DVM, Chair of the Review Panel

Dr. Lewis received his Doctor of Veterinary Medicine degree from the Ontario Veterinary College, University of Guelph, and practiced in Vancouver, BC for four years. Returning to academia, he earned his Master of Veterinary Science (MVSc) degree in Veterinary Pathology from the University of Saskatchewan.

Dr. Lewis completed the requirements for a Diploma in Public Sector Administration at the University of Victoria and was promoted to Chief Veterinary Officer and Director of the Animal Health Branch, a position in which he served from 1999 to 2009. During this time, he was the designated spokesperson on all animal health-related issues for the BC government.

As a member of the Accreditation Committee of the American Association of Veterinary Laboratory Diagnosticians (AAVLD), he helped to assess diagnostic laboratory services in several US states and Canada. For three years, he led the Animal Health Branch through the planning, development and implementation of the Containment Level 3 laboratory addition to the Animal Health Centre in 2008, a first for Canada.

Significant awards include the Ken Wells Award from CFIA for contributions to Canada's animal health programs; the Hill's Public Relations Award from the Canadian Veterinary Medical Association; a Life Member award from the AAVLD; and the Minister's Award of Excellence from the BC Minister of Agriculture.

Following retirement, he has been active in several domestic and international initiatives.

Dr. Lewis chairs the Editorial Committee of the Canadian Veterinary Medical Association and is an active member of the Abbotsford-Sumas Rotary Club.

André Corriveau, MD, Member of the Review Panel

Dr. André Corriveau is currently the Chief Public Health Officer with the Department of Health and Social Services, Government of the Northwest Territories, a position he has held since June 2012, as well as previously under the title of Chief Medical Health Officer from 1997 to 2009. Since April 2010, he has also served as the Provincial/Territorial co-chair of the Pan-Canadian Public Health Network.

Dr. Corriveau is a graduate of the Faculty of Medicine of McGill University and later obtained a Master's in Business Administration from Laval University. He is also a Fellow of the Royal College of Physicians and Surgeons of Canada as a specialist in Public Health and Preventive Medicine. Dr. Corriveau's varied career includes working as a family physician and Director of Professional Services for the Inuulitsivik Health Centre in Nunavik, Quebec, a part-time medical coroner, a medical officer of health in Nova Scotia and Chief Medical Officer of Health for the province of Alberta from 2009 to 2012.

Dr. Corriveau is an adjunct professor with the Faculty of Medicine of the University of Calgary and has been involved with a number of advisory councils and boards over the years.

W. Ronald Usborne, PhD, Member of the Review Panel

Dr. Usborne was formerly Chair of the Department of Food Science with the University of Guelph, Vice President of Food Safety and Technical Services with Caravelle Foods, and Chair of the Technical Committee of the Canadian Meat Council. He has participated in a number of McDonald's Corporation activities as well as academic, government, and industry advisory boards, committees, and councils. Currently, he is a member of the Expert Advisory Panel to the Canadian Food Inspection Agency.

Dr. Usborne has been recognized for his contributions to food safety and the meat industry by the Ontario Food Protection Association, the International Association of Food Protection, the Canadian Meat Council, the American Meat Science Association, and the Ontario Independent Meat Processors. Dr. Usborne retired from Caravelle Foods in 2004 and currently is conducting food safety and quality assessments and advising on HACCP programs and associated problems for both the food industry and government.

Appendix III – Who We Heard From By Organization

Agriculture and Agri-Food Canada

  • Anna Romano (A/Director General, Policy Development and Analysis)

Alberta Agriculture, Food and Rural Development

  • Gregg Orriss (Executive Director, Food Safety and Animal Health)

Alberta Cattle Feeder's Association

  • Sherry Monk (Communications)
  • Bryan Walton (Chief Executive Officer)

Alberta Health

  • Mickey Elabdi (Acting Director, Communications)
  • Dawn Friesen (Executive Director, Health Protection)
  • Victor Mah (Environmental Health Specialist)
  • Jim Talbot (Chief Medical Health Officer)

Alberta Health Services

  • Mark Fehr (Manager, Environmental Health, Central and Special Projects)
  • Lance Honish (Environmental Publish Health, Provincial Outbreak Management Lead)
  • Chris Sikora (Senior Medical Health Officer)
  • Ingrid Zazulak (Environmental Health Officer, Enteric Disease Specialist)

BioNiche One Health

  • Rick Culbert (President)
  • Susan Goebel (E. coli Project Manager)

Canadian Cattlemen's Association

  • Mark Klassen (Director, Technical Services)
  • Dennis Laycraft (Executive Vice-President)

Canadian Food Inspection Agency

  • Rick Armstrong (Meat Hygiene Inspector, Registered Establishment 38)
  • Richard Arsenault (A/Executive Director, Agri-food, Meat and Seafood Safety)
  • Stephen Baker (Vice President, Operations)
  • Amandeep Bath (Inspection Manager, Meat Programs, Western)
  • George Da Pont (President)
  • Satnam Dhothar (Managing Veterinarian, Establishment 38)
  • Martine Dubuc (Vice-President/Chief, Food Safety Officer for Canada, Vice-President, Science)
  • Wendy Fairs (Area Operations Coordinator)
  • Joe Freamo (Head of Audit)
  • Tom Hauschild (Director, Food Safety Assessment & Recall Operations)
  • Barbara Jordan (Associate Vice President, Operations)
  • Dr. Harpreet Kochhar (Executive Director, Western Operations)
  • Paul Littlewood (Regional Director, Alberta, South Calgary)
  • Bashir Manji (Executive Director, Office of Food Safety and Recall)
  • Sarbjit Mutti (Regional Recall Coordinator, Alberta, Nunavut and NWT )
  • Gagandeep Sekhon (Veterinarian, Registered Establishment 38)
  • Vince Steene (Meat Hygiene Inspector, Registered Establishment 38)
  • Bob Tomasta (Meat Hygiene Supervisor, Registered Establishment 38)
  • Linda Webster (A/Director, Strategic Partnerships Division)

Canadian Meat Council

  • Dr. Merv Baker (Chair, O157:H7 Sub-Committee)
  • Ron Davidson (Director, Government and Media Relations)
  • Dan Etzler (Cargill Meat Solutions)
  • Jim Laws (Executive Director)
  • Yemi Ogunrinola (Vantage Foods)
  • Jodie Robertson (JBS)
  • Art Rogers (JBS)

Cardinal Meats

  • Brent Cator (President)
  • Michael Rogers (Director of Technical Services)
  • John Vatri (Director of Operations)

Cargill Meat Solutions

  • Dr. Angie Siemens (Global Food Safety and Risk Management Leader)

Costco

  • Claude Gravel (Assistant General Merchandise Manager, Director of Operations, Meat)
  • Marcelle Lavergne (Director of Food Safety and Quality Assurance)
  • Janet Shanks (Vice President, Fresh Foods, Food Safety and Quality Assurance)

Health Canada

  • Enrico Buenaventura (Section Head, Risk Assessment, Evaluation Division)
  • Helene Couture (Chief, Evaluation Division)
  • Martin Duplessis (Head, Food Emergency Preparedness and Response Unit)
  • Jeff Farber (Director, Bureau of Microbial Hazards)

JBS

  • Dr. John Ruby (Vice-President, Technical Services – Beef Division)

Public Health Agency of Canada

  • Ryan Baker (A/Director, Strategic Communications)
  • Frank Plummer (Chief Science Officer)
  • Greg Taylor (Deputy Chief Public Health Officer)
  • Mark Raizenne (Director General, Centre for Foodborne, Environmental and Zoonotic Infectious Diseases)
  • Mark Samadhin (Director, Outbreak Management Division)

Public Service Alliance of Canada's Agriculture Union

  • Bob Kingston (National President)

Retail Council of Canada

  • Jennifer Amirault (Metro)
  • Sherry Casey (Loblaw)
  • Neil Checketts (Sobey's)
  • Katherine di Tommaso (Walmart)
  • Jane Holick (Walmart)
  • Marcel Lavergne (Costco)
  • Karen Proud (Vice-President, Federal Government Relations)
  • David Wilkes (Senior Vice-President, Government Relations and Grocery Division)

United Food and Commercial Workers

  • Doug O'Halloran (President, Local 401)

United States Department of Agriculture Food Safety Inspection Service

  • Al Almanza (Administrator)
  • Dr. Dan Englejohn (Assistant Administrator, Office of Field Operations)

University of Calgary

  • Dr. Bonnie Buntain (Faculty of Veterinary Medicine)

XL Foods Inc.

  • Brian Kaliel (Lawyer, Miller Thomson)
  • Warren Klymchuk, Quality Assurance Manager, XL Foods Inc.
  • Bryan Nilsson (Co-Owner)
  • Brian Read (Vice-President, Government and Industry Relations)

By Interviewee

Al Almanza
Administrator, United States Department of Agriculture's Food Safety Inspection Service
Jennifer Amirault
Metro, Retail Council of Canada
Rick Armstrong
Meat Hygiene Inspector, Registered Establishment 38, Canadian Food Inspection Agency
Richard Arsenault
A/Executive Director, Agrifood, Meat and Seafood Safety, Canadian Food Inspection Agency
Dr. Merv Baker
Chair, O157:H7 Sub-Committee, Canadian Meat Council
Ryan Baker
A/Director, Strategic Communications, Public Health Agency of Canada
Stephen Baker
Vice President, Operations, Canadian Food Inspection Agency
Amandeep Bath
Inspection Manager, Meat Programs, Western, Canadian Food Inspection Agency
Enrico Buenaventura
Section Head, Risk Assessment, Evaluation Division, Health Canada
Dr. Bonnie Buntain
Faculty of Veterinary Medicine, University of Calgary
Sherry Casey
Loblaw, Retail Council of Canada
Brent Cator
President, Cardinal Meats
Neil Checketts
Sobey's, Retail Council of Canada
Helene Couture
Chief, Evaluation Division, Health Canada
Rick Culbert
President, BioNiche One Health
George Da Pont
President, Canadian Food Inspection Agency
Ron Davidson
Director, Government and Media Relations, Canadian Meat Council
Satnam Dhothar
Managing Veterinarian, Establishment 38, Canadian Food Inspection Agency
Katherine di Tommaso
Walmart, Retail Council of Canada
Martine Dubuc
Vice-President/Chief, Food Safety Officer for Canada, Vice- President, Science, Canadian Food Inspection Agency
Martin Duplessis
Head, Food Emergency Preparedness and Response Unit, Health Canada
Mickey Elabdi
Acting Director, Communications, Alberta Health
Dr. Dan Englejohn
Assistant Administrator, Office of Field Operations, United States Department of Agriculture's Food Safety Inspection Service
Dan Etzler
Canadian Meat Council, Cargill Meat Solutions
Wendy Fairs
Area Operations Coordinator, Canadian Food Inspection Agency
Jeff Farber
Director, Bureau of Microbial Hazards, Health Canada
Mark Fehr
Manager, Environmental Health, Central and Special Projects, Alberta Health Services
Joe Freamo
Head of Audit, Canadian Food Inspection Agency
Dawn Friesen
Executive Director, Health Protection, Alberta Health
Susan Goebel
E. coli Project Manager, BioNiche One Health
Claude Gravel
Assistant General Merchandise Manager, Director of Operations, Meat, Costco
Tom Hauschild
Director, Food Safety Assessment & Recall Operations, Canadian Food Inspection Agency
Jane Holick
Walmart, Retail Council of Canada
Lance Honish
Environmental Publish Health, Provincial Outbreak Management Lead Alberta Health Services
Barbara Jordan
Associate Vice President, Operations, Canadian Food Inspection Agency
Brian Kaliel
Lawyer, Miller Thomson
Bob Kingston
National President, Public Service Alliance of Canada's Agriculture Union
Mark Klassen
Director, Technical Services, Canadian Cattlemen's Association
Dr. Harpreet Kochhar
Executive Director, Western Operations, Canadian Food Inspection Agency
Marcelle Lavergne
Director of Food Safety and Quality Assurance, Costco, and member of Retail Council of Canada
Jim Laws
Executive Director, Canadian Meat Council
Dennis Laycraft
Executive Vice-President, Canadian Cattlemen's Association
Paul Littlewood
Regional Director, Alberta, South Calgary, Canadian Food Inspection Agency
Victor Mah
Environmental Health Specialist, Alberta Health
Bashir Manji
Executive Director, Office of Food Safety and Recall, Canadian Food Inspection Agency
Sherry Monk
Communications, Alberta Cattle Feeder's Association
Sarbjit Mutti
Regional Recall Coordinator, Alberta, Nunavut and NWT, Canadian Food Inspection Agency
Bryan Nilsson
Co-Chief Executive Officer, XL Foods Inc.
Doug O'Halloran
President, Local 401, United Food and Commercial Workers
Gregg Orriss
Executive Director, Food Safety and Animal Health, Alberta Agriculture, Food and Rural Development
Yemi Orunrigola
Canadian Meat Council, Vantage Foods
Frank Plummer
Chief Science Officer, Public Health Agency of Canada
Karen Proud
Vice-President, Federal Government Relations, Retail Council of Canada
Mark Raizenne
Director General, Centre for Foodborne, Environmental and Zoonotic Infectious Diseases, Public Health Agency of Canada
Brian Read
Vice President, Government and Industry Relations, XL Foods Inc.
Jodie Robertson
Canadian Meat Council, JBS
Art Rogers
Canadian Meat Council, JBS
Michael Rogers
Cardinal Meats
Anna Romano
A/Director General, Policy Development and Analysis, Agriculture and Agri-Food Canada
Dr. John Ruby
Vice-President, Technical Services – Beef Division, JBS
Mark Samadhin
Director, Outbreak Management Division, Public Health Agency of Canada
Gagandeep Sekhon
Veterinarian, Registered Establishment 38, Canadian Food Inspection Agency
Chris Sekora
Senior Medical Health Officer, Alberta Health Services
Janet Shanks
Vice President, Fresh Foods, Food Safety and Quality Assurance, Costco
Dr. Angie Siemens
Vice-President, Technical Services, Meat Division, Cargill Meat Solutions
Vince Steene
Meat Hygiene Inspector, Registered Establishment 38, Canadian Food Inspection Agency
Jim Talbot
Chief Medical Health Officer, Alberta Health
Greg Taylor
Deputy Chief Public Health Officer, Public Health Agency of Canada
Bob Tomasta
Meat Hygiene Supervisor, Registered Establishment 38, Canadian Food Inspection Agency
John Vatri
Director of Operations, Cardinal Meats
Bryan Walton
Chief Executive Officer, Alberta Cattle Feeder's Association
Linda Webster
A/Director, Strategic Partnerships Division, Canadian Food Inspection Agency
David Wilkes
Senior Vice-President, Government Relations and Grocery Division, Retail Council of Canada
Ingrid Zazulak
Environmental Health Officer, Enteric Disease Specialist, Alberta Health Services

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Goetz, Gretchen. UK Approves E. coli O157:H7 Vaccine for Cattle. Food Safety News. August 10, 2012.

Greig, J.D. et al. The efficacy of interventions applied during primary processing on contamination of beef carcasses with Escherichia coli: A systematic review-meta- analysis of the published research. Food Control 27: 385-397, 2012

Hurd, H. Scott and S. Malladi. An Outcomes Model to Evaluate Risks and Benefits of Escherichia coli Vaccination in Beef Cattle. Foodborne Pathogens and Disease 9: 953-961, 2012

Alberta, Government of, Alberta Livestock and Meat Agency, Alberta Innovates Bio Solutions, Health Canada, Agriculture and Agri-food Canada, the University of Alberta and the Beef Cattle Research Council. Interventions to Minimize Risk of E. coli O157 and non-O157 STECs in Beef. List of abstracts compiled by the ad hoc Strategic Pathogen Reduction Working Group. November 2012.

Jadeja, R., Y. Hung, J.M. Bosilevac. 2012. Resistance of various Shiga toxin-producing Escherichia coli to electrolyzed oxidizing water. Food control. 30:580-584.

Karmali, M. A. et al. Verocytotoxin-producing Escherichia coli (VTEC). Veterinary Microbiology 140: 360-370, 2010

Marler, William (Bill). Marler Blog. Providing commentary on food poisoning outbreaks and litigation. 2011. E. coli bacteria: what are they, where did they come from, and why are some so dangerous?

Moxley, R.A. et al. Escherichia coli 0157:H7 Vaccine Dose - Effect in Feedlot Cattle. Foodborne Pathogens and Disease 6: 879-884, 2009.

National Forum on Food Safety. Draft Interim Report. Edmonton Alberta. January 11-12, 2012.

Oliver, S.P. et al. ASAS Centennial Paper: Developments and future outlook for preharvest food safety. J. Anim. Sci. 87: 419-437, 2009.

Powell, D.A. et al. Audits and inspections are never enough: A critique to enhance food safety. Food Control 30: 686-691, 2013.

PRNewswire. Bioniche E. coli O157 Vaccine to be Used in an On-Farm Intervention Study in Sweden. April 18, 2013. Belleville, Ontario.

Public Health Agency of Canada. Deaths associated with enteric infections, 2000 to 2004, CIHI and Vital Statistics (Statistics Canada). Incidence of E. coli reported to PHAC through the National Enteric Surveillance Program, 2002 to 2011.

Public Health Agency of Canada. Public Health Notice. E. coli O157 illness related to beef. Updated December 21, 2012.

Rangel, J.M., P.H. Sparling, C. Crowe, P.M. Griffin, D.L. Swerdlow. Epidemiology of Escherichia coli O157:H7 outbreaks, United States, 1982–2002. Emerging Infectious Diseases, Volume 11, Number 4 – April 2005. Available from: http://www.nc.cdc.gov/eid/article/11/4/04-0739.htm

Sargeant, J.M., M.R. Amezcua, A. Rajic and L. Waddell. 2007. Pre-harvest Interventions to Reduce the Shedding of E. coli O157 in the Faeces of Weaned Domestic Ruminants: A Systematic Review. Zoonoses and Public Health, 54 (2007) pp. 260–277.

Smith, B.A. et al. A risk assessment model for Escherichia coli O157:H7 in ground beef and beef cuts in Canada: Evaluating the effects of interventions. Food Control 29: 364-381, 2013.

Smith, D.R. et al. A Randomized Longitudinal Trial to Test the Effect of Regional Vaccination Within a Cattle Feedyard on Escherichia coli O157:H7 Rectal Colonization, Fecal Shedding, and Hide Contamination. Foodborne Pathogens and Disease 6: 885-892, 2009.

Smith, G.G. et al. Reducing the Public Health Risk of Escherichia coli O157:H7 Exposure by Immunization of Cattle. Canadian Journal of Public Health. 104: e9- e11, 2013.

Soon, J.M. et al. Escherichia coli O157:H7 in beef cattle: on farm contamination and pre- slaughter control methods. Animal Health Res. Reviews 12: 197-211, 2011.

Stephens, T.P., G.H. Loneragan, E. Karunasena, M.M. Brashears. 2007. Reduction of Escherichia coli O157 and Salmonella in feces and on hides of feedlot cattle using various doses of a direct-fed microbial. J. Food Prot. 70:2386-2891.

van Donkersgoed, J., et al. Escherichia coli O157:H7 vaccine field trial in nine feedlots in Alberta and Saskatchewan. Can. Vet. J. 46: 724-728, 2005.

Varela, N.P. et al. Assessing the Existing Information on the Efficacy of Bovine Vaccination against Escherichia coli O157:H7 – A Systematic Review and Meta-analysis. Zoonoses and Public Health 1-16, 2012.

In addition, to a wide variety of supporting documentation, the Panel was also provided with large numbers of presentations by federal government staff on a variety of related topics including:

  • Mechanically tenderized beef
  • Food recall and emergency response
  • CFIA Framework for Food Safety Investigation and Response
  • Control of E. coli O157:H7 in Raw Beef Products in Federally Registered Establishments. Planned changes. Calgary, Alberta. February 2013.
  • Health Canada Initiatives on E. coli O157 and non-O157 in Beef
  • The Role of Post-Harvest Interventions in the Control of Bacterial Pathogens on Beef
  • National Strategy for Safe Food. F/P/T Members of the F/P/T Food Safety Committee. September 2008
  • Canada's Foodborne Illness Outbreak Response Protocol (FIORP) 2010
  • Weight of Evidence: Factors to Consider for Appropriate and Timely Action in a Foodborne Illness Outbreak Investigation, January 2011
  • Action on Weatherill Report Recommendations to Strengthen the Food Safety System: Final Report to Canadians. December 2011

Glossary

Compliance Verification System (CVS) – A task-based tool used by Canadian Food Inspection Agency (CFIA) inspection staff to verify that the industry complies continually with federal food safety regulations and policies. The CVS contains some 90 tasks that must be performed variously on a daily, weekly, monthly or yearly basis. As a tool, it ensures that each inspection is conducted consistently, efficiently, and in a uniform fashion – no matter who conducts it, or which type of plant is reviewed.

Foodborne illness – A human illness, with evidence indicating a food was the source of exposure to the contaminant causing illness. Foodborne illness occurs when a person consumes food contaminated with bacteria, viruses, parasites, or toxins.

Foodborne Illness Outbreak Response Protocol (FIORP) – A series of technical and operational procedures for federal and provincial/territorial food safety partners when responding during multi-jurisdictional foodborne illness outbreaks.

Food Safety Enhancement Program (FSEP) – A CFIA program that specifies the minimum requirements for an effective food safety management system based on HACCP principles and encourages its development, implementation and maintenance in all federally registered establishments, excluding federally registered fish establishments.

Hazard Analysis and Critical Control Point (HACCP) – A systematic approach to identifying and assessing hazards and risks associated with a food operation and defining the means of their control.

Health Risk Assessment (HRA) – A scientifically based process conducted by Health Canada to establish whether a specific adverse health effect is likely to occur in an individual or a population exposed to a hazardous agent.

High Event Period (HEP) – A high event period is one in which a processing plant experiences a high number of positive results for E. coli O157:H7 in samples that came from the same production lot.

Multiple-hurdle approach – Any combination of a number of interventions adopted by beef producers and processors to contribute to maximizing food safety.

Multiple Loci VNTR Analysis (MLVA) – A method used to genetically analyze microorganisms (such as pathogenic bacteria). "VNTR" means Variable Number of Tandem Repeats.

Outbreak Investigation Coordination Committee (OICC) – A committee with representation from the partners who are actively involved in a specific outbreak, to coordinate a multi- agency response to a foodborne illness outbreak in Canada.

Post-harvest intervention – The application of control measures after the product has been harvested to reduce, prevent or possibly eliminate food safety risks and/or to control potential microbiological hazards (in the case of beef, interventions generally occur in the processing plant).

Pre-harvest intervention – The application of control measures before the product has been harvested to reduce, prevent or possibly eliminate food safety risks and/or to control potential microbiological hazards (in the case of beef, these generally occur in the field or on the farm).

Prerequisite Plan (PP) – Steps or procedures that control the operational conditions within a food establishment and promote environmental conditions that are favourable for the production of safe food.

Pulsed Field Gel Electrophoresis (PFGE) – A molecular "fingerprinting" technique used to separate large DNA molecules and classify bacteria. An alternating electric field known as pulsed-field gel electrophoresis is used.

PulseNet Canada – A critical surveillance system used to quickly identify and respond to foodborne disease outbreaks. A standardized laboratory method permits inter-laboratory comparison and communication of information about foodborne illnesses, indicating a common source of food contamination.

Super shedder – An individual (e.g., cow) that produces considerably more infectious organisms of a given type for a period of time than most other individuals of the same species.