Listeriosis: What happened with Maple Leaf Quebec Cheese

1. Listeriosis: What happened with Maple Leaf & Quebec Cheese?� Eleni Galanis and Sion Shyng BC Centre for Disease Control BCFPA Oct 9 2008 -serious illness (hi CFR) -increase IR worldwide -ubiquitous in environment -2 recent outbreaks in BC -be aware of unusual/new sources-serious illness (hi CFR) -increase IR worldwide -ubiquitous in environment -2 recent outbreaks in BC -be aware of unusual/new sources

2. Outline Eleni What are Listeria and listeriosis? Epidemiology of the Maple Leaf outbreak Sion Recall of Maple Leaf product Multi-agency response in BC Highlights of Maple Leaf & Quebec cheese outbreaks

3. What are Listeria and listeriosis?

4. Some definitions Listeria: bacterium Listeria monocytogenes (LM): species pathogenic to humans Listeriosis: illness caused by Listeria

5. Where do Listeria live and how do they get to us? Reservoir Primary: soil and decaying vegetation Secondary: gut of animals Transmission to humans Through contaminated food From mother to fetus in utero

6. Food sources Unpasteurized dairy Soft cheeses Deli meats Smoked/raw fish and meats Pate Sausage Other RTE foods (e.g. cole slaw) Recovery rates of 2-92% in dairy and meat products1 2: some raw and unprocessed2: some raw and unprocessed

7. Listeria growth Listeria tend to multiply at refrigerator temperatures

8. How do Listeria make us sick? Ingestion Incubation: 10-70d (average 31d) Gastrointestinal infection Invasion into blood stream Dissemination to organs Neurological system Placenta

9. Clinical presentation and treatment Bacteremia / sepsis Meningitis Antibiotic treatment Death: 20-50%

10. Who is most at risk? Individuals with weakened immune systems (e.g. cancer, transplant recipients, people on corticosteroids) Elderly Pregnant women Neonates

11. How is listeriosis diagnosed in BC? Listeria is isolated in private/hospital labs Isolate is sent to BCCDC lab for confirmation Isolate is sent to National Microbiology Lab in Winnipeg for subtyping PFGE (DNA fingerprint) is used to link cases to each other or to a common source

12. Cases of invasive listeriosisBC, 1997-2008 (N=100)

13. Listeriosis by age and sex BC, 2002-07 (N=67)

14. 2008 Canadian outbreak associated with Maple Leaf meat: Epidemiology

15. Agencies involved in investigation

16. What happened when? PHAC informs BC of cases with matching PFGE Case 1: Aug 13 Case 2: Aug 18 Case 3: Aug 22 case 4: Aug 24 case 5: Sep 18 PHAC informs BC of cases with matching PFGE Case 1: Aug 13 Case 2: Aug 18 Case 3: Aug 22 case 4: Aug 24 case 5: Sep 18

17. Cases of listeriosis in the ML outbreak*

18. Deaths among cases of listeriosis in the ML outbreak

19. Cases of listeriosis by week of onset, ML outbreak, 2008* (N=52)

20. BC cases (N=5) Age: 29-68y 4 females, none pregnant All had underlying medical conditions which weakened their immune systems Exposures 4 ate ML deli meat in hospital prior to illness 1 ate ML deli meat in community 2 died of listeriosis

21. What was the source of the outbreak? Which product(s)? What time frame?

22. Exposures among Canadian cases Majority of cases indicated eating deli-meat Among these, majority reported eating Maple Leaf Foods deli-meat Among these, majority reported eating a particular brand of Maple Leaf Foods deli-meat primarily distributed in institutions

23. Periods at risk

24. Actions taken byBCCDC epidemiologists Identification and collection of data from cases and institutions Provision of information to public and physicians Media interviews Website Letters to physicians Regular mtgs and communication with health and food regulation partners Participation in the BC Food Safety in Facilities Advisory Group

25. First Maple Leaf Recall

26. BC�s Response to Food Recall Provincial Food Recall Manual Communication and collaboration between agencies Multi-Agency Response CFIA (Lead) BCCDC (Epi, FPS, Labs, PHO, MHLS) 5 Regional Health Authorities Product Distribution into BC?

27. Expanded Recall(23 Products from Lines 8 & 9)

28. BCCDC / RHA Response CFIA requests HA assistance for recall effectiveness checks with high risk facilities RHAs focus: Hospitals Community Care Residences Day Cares Identify/quarantine affected products CFIA responsible for contacting retailers/food service

33. 3rd Maple Leaf Recall(ALL Products from Est. 97B)

34. BCCDC / RHA Response Contact high risk establishments (expanded) Hospitals Community Residences Day Cares Soup Kitchens / Food Banks / Charities / Churches Medical Centers Public & Private Schools (and school boards) Assisted Living BC Restaurant Association 2nd Request for assistance made by the CFIA

35. RHA Actions >7100 facilities contacted Phone, e-mail, fax Majority had been contacted twice Follow up letters mailed out to daycares Example: FHA provided info for daycares could hand out to parents Enormous amount of resources mobilized

38. Plant Investigation Environmental and finished products sampled by CFIA Products tested by HC Isolates sent to NML for PFGE Positives associated with Lines 8 & 9 and �Sure Slice� products Public Health samples from LTCF 17 of 26 samples Lm positive

39. What was the problem? The contamination was most likely the result of a combination of factors including the potential for equipment to harbour organic material, employee and product movement, and the physical environment. Listeria is a naturally occurring environmental hazard that cannot be completely eliminated from the environment. What is important is that surfaces in direct contact with food, such as slicers, must be 100% free of contamination.

42. What are the conditions for the resumption of operations at the Maple Leaf Foods plant? The CFIA will allow limited trial runs for a three-day period where product will be held and tested each day based on a rigorous sampling plan. The effectiveness of inspection and processing controls will also be validated. Production will stop until test results come back. Only if test results are negative and operating procedures are determined to be in compliance will the company be able to begin broader production. For the following six weeks all product will be held and tested in lots and will only be released if negative test results are received.

43. First Quebec Cheese Recall

44. MAPAQ Investigation Late Aug � Listeria linked to cheese Different PFGE pattern than ML outbreak Intensive investigation of raw milk cheese producers (considered higher risk) 43 raw milk cheese producers inspected 3 plants found Lm positive

45. Raw Milk Cheeses Implicated Medard de St-Gedeon of Lac-St-Jean, Que 8 cheeses recalled The Fromagiers de la table ronde, Ste-Sophie, Que. 3 cheeses recalled Ulverton Farm 2 cheeses sold only at plant Lm found on the work surfaces and in the finished products

46. Listeriosis Linked to Cheeses 22 cases 1 death 7 pregnant women 6 premature deliveries 1 stillbirth Cheese at 300 retailers discarded (cross contamination potential)

47. Salmonella Linked to Cheese Fromages La Chaudiere Unripened cheese Salmonella enteritidis 87 cases 1 death

48. MAPAQ Review of Pasteurized Milk Cheese Producers Province-wide investigation into pasteurization processes at all 200 producers of pasteurized-milk cheese. La Fromagerie La Voie Lact�e recalled 6 cheeses "inadequate pasteurization�, not linked to listeriosis

49. BC�s Experience 2 Listeriosis outbreaks in 2002 Pasteurized, soft mold ripened cheese Chronic disability Miscarriage(s) Contaminated water (post pasteurization) Contamination of mold culture solution

50. Concerns Aged, hard raw milk / heat treated cheese ? lower risk Pasteurized, soft mold ripened cheese ? high risk �Raw milk�, �unpasteurized�, �unrefined� soft mold ripened cheese ? HIGH RISK � no kill step Health Canada survey of imported & domestic raw milk cheeses (n=382) 2% Lm positive!

51. Health Hazard Alerts September 2008 September 24 - HEALTH HAZARD ALERT - HYGAARD brand SANDWICH PRODUCTS may contain Listeria monocytogenes September 23 - HEALTH HAZARD ALERT - Cheese manufactured by FROMAGERIE LA VOIE LACT�E INC. may be contaminated by pathogenic bacteria September 19 - HEALTH HAZARD ALERT - Pr�sence de Listeria monocytogenes - Fromages � ne pas consommer - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ) September 18 - HEALTH HAZARD ALERT - SMITH SNACKS brand PRODUCTS may contain Listeria monocytogenes September 12 - CORRECTED HEALTH HAZARD ALERT - Various cheese products produced by IVANHOE CHEESE INC. may contain Listeria monocytogenes September 11 - EXPANDED HEALTH HAZARD ALERT - Various cheese products produced by IVANHOE CHEESE INC. may contain Listeria monocytogenes September 10 - EXPANDED HEALTH HAZARD ALERT - Various cheese products produced by IVANHOE CHEESE INC. may contain Listeria monocytogenes September 10 - HEALTH HAZARD ALERT - MERIT SELECTION DELICATESSEN COOKED EXTRA LEAN HAM may contain Listeria monocytogenes September 9 - HEALTH HAZARD ALERT - Rappel important de fromages - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ) September 9 - HEALTH HAZARD ALERT - Pr�sence de Listeria monocytogenes - Fromages � ne pas consommer - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ) September 5 - UPDATED HEALTH HAZARD ALERT - Various cheese products produced by IVANHOE CHEESE INC. may contain Listeria monocytogenes September 5 - HEALTH HAZARD ALERT - Various STORE-MADE SANDWICHES and PARTY TRAYS including FRESH 2 GO (F2GO) products may contain Listeria monocytogenes September 5 - HEALTH HAZARD ALERT - Rappel important de fromages - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ) September 4 - UPDATED HEALTH HAZARD ALERT - Various cheese products produced by IVANHOE CHEESE INC. may contain Listeria monocytogenes September 4 - HEALTH HAZARD ALERT - CANEX brand MAPLE LEAF BOLOGNA may contain Listeria monocytogenes September 4 - HEALTH HAZARD ALERT - Pr�sence de Listeria monocytogenes - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ) September 3 - HEALTH HAZARD ALERT - Various cheese products produced by IVANHOE CHEESE INC. may contain Listeria monocytogenes September 3 - HEALTH HAZARD ALERT - Fromages de � Les Fromagiers de la Table Ronde� � ne pas consommer - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ) September 2 - EXPANDED - HEALTH HAZARD ALERT - Various fresh cheeses manufactured by FROMAGES LA CHAUDI�RE may be contaminated with Salmonella September 2 - HEALTH HAZARD ALERT - Fromages portionn�s � l'entreprise Aux Petits D�lices GT � ne pas consommer - Le minist�re de l'Agriculture, des P�cheries et de l'Alimentation (MAPAQ)

52. The Ripple Effect Policies Regulatory Agencies Industry HACCP Industry Risk Assessment Serving high risk populations

53. Acknowledgements BCCDC Epi/FPS/Labs BC regional Health Authorities BC Ministry of Healthy Living and Sports Canadian Food Inspection Agency National Microbiology Lab Public Health Agency of Canada

54. Questions?