Canada’s Foodborne Illness Outbreak Response Protocol (FIORP) 2010: To guide a multi-jurisdictional response

Table of Contents

• Preamble
• 1. DEFINITIONS
• 2. INTRODUCTION
• 3. PURPOSE
• 4. SCOPE
• 5. GUIDING PRINCIPLES
• 6. ROLES AND RESPONSIBILITIES
  • 6.1 Provincial/Territorial Authorities
  • 6.2 Federal Authorities
    • 6.2.1 Public Health Agency of Canada
    • 6.2.2 Health Canada
    • 6.2.3 Canadian Food Inspection Agency
  • 6.3 Other Agencies or Organizations
• 7. OPERATING PROCEDURES
  • 7.1 Notification Between Partners of a Potential Multi-Jurisdictional Food-borne Illness Outbreak
  • 7.2 Determination of a Potential Multi-Jurisdictional Food-borne Illness Outbreak
    • 7.2.1 Human Illness Potentially Linked to Food
    • 7.2.2 Identification of a Food-borne Hazard that Could Cause Human Illness
  • 7.3 Initial Assessment/Review of Information and Activation of the Outbreak Investigation Coordinating Committee (OICC)
  • 7.4 Outbreak Investigation Coordinating Committee (OICC)
    • 7.4.1 Purpose of the OICC
      • 7.4.1.1 Decision-Making and Resolving Differences of Opinion
    • 7.4.2 Outbreak Investigation Coordinating Committee (OICC)
      • 7.4.2.1 Composition of the OICC
      • 7.4.2.2 Determination of the OICC Lead
      • 7.4.2.3 Responsibilities of the OICC Lead
      • 7.4.2.4 FIORP Duty Officers
  • 7.5 Investigations
    • 7.5.1 Epidemiological Investigations
    • 7.5.2 Food Safety Investigations
    • 7.5.3 Laboratory Investigations
  • 7.6 Centralized Integrated Analysis
  • 7.7 Health Risk Assessment (HRA)
  • 7.8 Public Health and Food Safety Actions
    • 7.8.1 Tampering and Terrorism
    • 7.8.2 Exchange of Industry Information
  • 7.9 Communication with the Public
    • 7.9.1 Responsibility
    • 7.9.2 Public Communications Activities and Content
  • 7.10 Outbreak Conclusion
  • 7.11 Outbreak Debrief/Review
• 8. ADMINISTRATIVE REVIEW
• 9. EMERGENCY OPERATIONS CENTRE (EOC) ACTIVATION AND INCIDENT COMMAND SYSTEM (ICS)
• 10. SUPPORTING DOCUMENTS/REFERENCES
• 11. LIST OF ACRONYMS
• Annexes

Preamble

The investigation of and response to multi-jurisdictional food-borne illness outbreaks in Canada may involve several organizations at multiple levels of government with complementary responsibilities. The Foodborne Illness Outbreak Response Protocol (FIORP) was collectively developed by the Public Health Agency of Canada (PHAC), Health Canada (HC), and the Canadian Food Inspection Agency (CFIA), in consultation with provincial/territorial (P/T) stakeholders, to enhance the collaboration and overall effectiveness of response during multi-jurisdictional food-borne illness outbreaks.

The first edition of the FIORP was developed in 1999 by HC and the CFIA, in consultation with the provinces and territories (P/T).  In 2002, the former Federal/Provincial/Territorial (F/P/T) Committee on Food Safety Policy (FPTCFSP) recognized the FIORP as a key procedural document in national emergency preparedness, and identified a need to review this document and seek senior management endorsement.  The FIORP was endorsed by the FPTCFSP, the Council of Chief Medical Officers of Health (CCMOH), and the F/P/T Deputy Ministers of Health in 2004. In 2006 the document was further revised to reflect the role of PHAC.  The current version was developed after consultation with F/P/T stakeholders throughout 2009 and the receipt of endorsement by the F/P/T Deputy Ministers of Health and Agriculture and Agri-Food, along with their respective supportive committees, F/P/T Food Safety Committee, CCMOH, etc.

The contributions of all the individuals who participated in the revision and consultation process are gratefully appreciated.

Contact for FIORP:  The Centre for Food-borne, Environmental and Zoonotic Infectious Diseases (CFEZID), within the Infectious Disease Prevention and Control Branch (IDPC) at the Public Health Agency of Canada (PHAC)

1. DEFINITIONS

The following definitions are provided to ensure a common understanding of the terms in this document:

Centralized Integrated Analysis: When multiple agencies are involved, centralized collation and analysis of data by the Outbreak Investigation Coordinating Committee (OICC) lead agency is required to inform decision-making and draw conclusions based on all available data.

Cluster: An unusual aggregation of similar health events, generally grouped together as they appear over a particular time period or geographical area. A cluster may be seen as the occurrence of cases of disease (human illnesses) in excess of what is usually expected for a given period of time. A cluster may or may not reach the status of an “outbreak.” The use of the term is particularly common in describing the results of subtype-based surveillance, which may detect a cluster of infections caused by similar microbial strains.

Emergency Operations Centre (EOC): The physical location where an organization comes together during an emergency to coordinate response and recovery actions, and resources. These centres may alternatively be called command centres, situation rooms, war rooms, crisis management centres, or other similar terms. Regardless of the term, this is where the coordination of information and resources takes place. The EOC is not an incident command post; rather, it is the operations centre where coordination and management decisions are facilitated.

Epidemiological investigation: Investigation made to determine the existence of an outbreak; to characterize it over a specific time period, geographical area and describe personal characteristics of cases; and to develop and test a hypothesis explaining the specific exposure that caused disease.  The investigation may result in recommendations towards the implementation of appropriate prevention and mitigation measures.

Epidemiological evidence: The demonstration of an association between a food and human illness through an increase in cases in a population, place, or timeframe with exposure to the same food product; or a statistically significant association between illness and food.

Evidence: That which demonstrates or shows an association between events.  Evidence of an association between a consumed food and human illness may be epidemiological and/or based on the results of food safety investigations or laboratory analysis.

FIORP duty officer: Each partner will appoint a primary designated representative (by named position within their respective organization) who will be responsible for briefing senior officials within their organization and ensuring that their jurisdiction leads or participates in an OICC as required. The FIORP duty officers will be notified by the OICC lead when an OICC is to be established with participation by their organization and will be responsible for notifying and providing regular updates to their senior officials. Contact information for the FIORP duty officers will be maintained as part of the FIORP contact list.

Food: Includes any article manufactured, sold, or represented for use as food or drink for human beings, chewing gum, and any ingredient that may be mixed with food for any purpose whatsoever.

Food-borne hazard: A biological, chemical, or physical agent in, or condition of, food with the potential to cause an adverse health effect.

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

Food safety investigation: Inspection and related activities undertaken by regulatory officials to verify whether or not a food hazard which could cause human illness exists and to determine the nature and extent of the problem.

Health Risk Assessment (HRA): A scientifically based process which determines the likelihood that a specific adverse health effect will occur in an individual or a population, following exposure to a hazardous agent. The following steps are used in the development of a health risk assessment: 1) hazard identification; 2) hazard characterization; 3) exposure assessment; and 4) risk characterization.

Incident Command System (ICS): A standardized organizational structure used to command, control, and coordinate the use of resources and personnel that have responded to the scene of an emergency. The concepts and principles for ICS include common terminology, modular organization, integrated communication, unified command structure, consolidated action plan, manageable span of control, designated incident facilities, and comprehensive resource management.

Laboratory evidence: Evidence shown by the isolation/identification of the same pathogen, toxin, or contaminant from cases of human illness and the suspect food.

Multi-jurisdictional food-borne illness outbreak:  A food-borne illness outbreak  that occurs across more than one P/T or country and requires the resources of more than one F/P/T public health and/or food regulatory organization to investigate, or control it.

Outbreak: An incident in which two or more persons experience similar illness after a common source exposure.  An outbreak is identified through laboratory surveillance or an increase in illness that is unusual in terms of time and/or geography.  An outbreak is confirmed through laboratory and/or epidemiological evidence.

Partner: Any agency with a responsibility to investigate or respond to food-borne illness outbreaks in Canada including F/P/T health and agriculture and agri-food agencies that share food safety and public health responsibilities.
Ready-to-eat food: Foods not requiring any further preparation before consumption, except perhaps washing/rinsing, thawing, or warming.

Recall: The removal from sale, use, or correction, of a marketed product that poses a risk and/or contravenes a statute.

Response: In the context of food-borne illness outbreaks, response includes activities related to the determination, investigation, mitigation, and containment of such outbreaks, as well as related communication activities.

2. INTRODUCTION

Food-borne illness results from the natural, accidental, or malicious contamination of foods by microbiological or chemical substances. The impacts of food-borne illness may include morbidity and mortality, increased health care costs, loss of consumer confidence, economic losses, and lost productivity to industry.

Changes in food distribution networks and the increased globalization of trade in food have resulted in larger volumes of raw and processed products moving across domestic and international boundaries.  Consequently, food-borne illness outbreaks associated with widely distributed foods result in human illness that cross local, provincial/territorial and international boundaries.  Regulatory bodies responsible for human health and food safety respond to these events through the development of enhanced food-borne illness surveillance networks, including the use of molecular sub typing and other laboratory technology, to enable cluster detection and the linkage of seemingly unrelated cases to initiate outbreak investigation. Increased concern and public awareness of food safety has heightened the demand for swift resolution of food safety issues at a time when they are becoming increasingly complex, reinforcing the need for collaboration in multi-jurisdictional outbreak investigations and the active participation of all partners in centrally led efforts to mitigate risk and prevent further illness.

Food safety and public health are responsibilities shared by the Government of Canada and the provinces/territories (the partners). Collaboration among these partners and across jurisdictions is of utmost importance to effectively manage multi-jurisdictional food-borne illness outbreaks. The partners recognize that formalized approaches will facilitate such collaboration and cooperation, thereby protecting the health of Canadians.

The principal framework document which guides multi-jurisdictional collaboration in response to food-borne illness outbreaks in Canada is the Foodborne Illness Outbreak Response Protocol (FIORP). This document has been in use since 1999 and is periodically reviewed and shared with partners and other implicated public health professionals for their endorsement.

3. PURPOSE

The purpose of the FIORP is to set out the key guiding principles and operating procedures for the identification and response to multi-jurisdictional food-borne illness outbreaks in order to enhance collaboration and coordination among partners, establish clear lines of communication, and improve the efficiency and effectiveness of response, thereby protecting the health of Canadians.

It is designed to be used in response to illness outbreaks with a suspected or confirmed link to food consumed in Canada when more than one province/territory or country and multiple agencies are involved.

It can serve as a model for individual provinces/territories to develop their own food-borne illness outbreak response protocol when multiple jurisdictions/agencies within a single province/territory are engaged in the investigation and response.

The FIORP is not intended to provide detailed instructions on how to conduct investigation and response. Rather, it serves to guide the collaboration of the partners in the identification and response to multi-jurisdictional outbreaks. This includes guidance for notification of partners, communication, and information-sharing.

4. SCOPE

• 4.1 The FIORP describes activities beginning with the determination of a potential for multi-jurisdictional food-borne illness outbreak and ending with either the containment of the risk that triggered the outbreak or resolution of the outbreak. It also includes the post-outbreak review process.
• 4.2 The FIORP is intended to be used for outbreaks that affect, or have the potential to affect, more than one province/territory or country. Where more than one country is affected, the FIORP is intended to guide activities within Canada only.
• 4.3 Where an individual province/territory has a food-borne illness outbreak response protocol, it will guide outbreak investigation within that province/territory (P/T). The FIORP may also be used by a P/T to guide investigation and response if the outbreak is limited to a single P/T, where a food-borne illness outbreak response protocol does not exist.
• 4.4 The FIORP addresses potential food-borne illness outbreaks resulting from the natural, accidental, or intentional contamination of foods by microbiological, chemical, or other hazardous substances (e.g. radio nuclear hazards).
• 4.5 The principles outlined in the FIORP may also serve as a guide when human enteric illnesses are caused by non-food sources (e.g., contaminated pet treats, petting zoo animals, pets, etc.) or when other food hazards cause widespread human injuries requiring prompt collaboration and coordination (e.g., inert physical hazards).
• 4.6 The FIORP operating procedures focus primarily on developing a coordinated response that is needed to mitigate food-borne illness outbreaks. While the FIORP does not specifically address the broader risk assessment process that contributes to policy development and standard setting to reduce the risk of future outbreaks (occurrences), the opportunity to raise the need for future policy development to manage risk is provided for during the outbreak debrief/review (Section 7.11).

5. GUIDING PRINCIPLES

The principles underlying the FIORP are intended to guide the collaboration of the partners to maximize their effectiveness and efficiency during the investigation and response to multi-jurisdictional food-borne illness outbreaks.

• The primary objective of the activities described in the FIORP is to mitigate or contain the effects of a food-borne illness outbreak in a timely and effective manner, thereby protecting the health of Canadians.
• The FIORP will serve as the national reference document to guide the F/P/T response to outbreaks involving more than one P/T or country.
• PHAC will act as the custodian of the FIORP and will be responsible for the maintenance of the FIORP and its regular review in consultation with appropriate F/P/T partners.
• The partners are encouraged to raise awareness of the FIORP within their own jurisdiction by circulating the document to their senior management and their partners in food-borne illness outbreak investigation and response and by participating in simulation exercises/training where possible.
• Subject to applicable laws governing the sharing of information (including privacy, access to information and common law relating to confidential business information), the partners recognize that information required to investigate, control, and resolve a food-borne illness outbreak may be exchanged in confidence and in a timely fashion between the partners. This will be done when a food-borne illness outbreak, or food-borne health hazard that could pose a risk to public health, is identified and there is a clear public interest in sharing this information.
• The Outbreak Investigation Coordination Committee (OICC) established pursuant to this FIORP will serve as the main forum for information-sharing and interpretation, clarification of roles and responsibilities, establishment of response priorities, and the development of communications strategies related to an actual or suspected food-borne illness outbreak.
• The partners recognize that public disclosure of confidential business information may be required when a food-borne illness outbreak, or food-borne health hazard that could pose a risk to public health, is identified.
• Laboratory, epidemiological, or food safety investigation evidence is accepted for establishing the association between a particular food or foods and human illness.
• Whenever possible, the partners implementing the FIORP will provide assistance, including laboratory support, as requested during an epidemiological investigation or food safety investigation.
• The FIORP is intended to complement agreements and procedures established among the partners. Where memoranda of understanding (MOUs) or other agreements between the partners, regarding food safety surveillance, investigation or control, may exist or are negotiated, these will be shared and respected.
• The FIORP is not intended to substitute for the on-going relationships between the partners necessary to discharge other responsibilities and to manage issues as they arise.
• Canada, including the provinces and territories, is responsible for ensuring its obligations pursuant to the International Health Regulations (IHR 255) are met¹ .
• Publication of information in a related to multi-jurisdictional food-borne outbreaks investigated collaboratively through an OICC will not occur without the permission of all the partners engaged in the investigation and response.

6.  ROLES AND RESPONSIBILITIES

Responsibilities for responding to food-borne illness outbreaks may be shared between federal/provincial/territorial (F/P/T) and local/regional jurisdictions.  The response to such situations involves collaboration and cooperation among all those involved.  Annex 13 describes the legislative authorities within each of the F/P/T governments and provides more detailed roles and responsibilities for all the partners.

6.1 Provincial/Territorial Authorities

Local/regional health officials in individual P/Ts generally have the mandate to investigate human illness outbreaks that occur within their boundaries with local/regional medical officers of health taking a leadership role. Additionally, they have the responsibility to report food-borne pathogens to P/T health officials under disease control legislation. However, in certain P/Ts, other departments (including agriculture and agri-food) may also have a role in food-borne illness investigations. 

P/Ts have food safety legislation and may also carry out inspection and education activities to reduce risks related to food. P/T health officials conduct surveillance for enteric illnesses..Some P/Ts have their own individual food-borne outbreak response protocols to guide the collaborative response within the P/T and identify the lead should an outbreak span regional/local boundaries.  Should an outbreak span regional boundaries or have serious human health implications, a leadership role in investigation may be assumed by the P/T Chief Medical Officer of Health. The P/T food regulatory officials are often called to participate and may lead the response under some P/T protocols. During their investigations, the various P/Ts or local/regional authorities may take steps to control potential causes of food-borne illness. In addition, the territories have responsibilities for the investigation of food-borne illness outbreaks that occur in First Nations North of 60°.

Local/regional or P/T officials may also, in some cases, request the assistance of HC, PHAC, or CFIA in the response to a potential food-borne illness outbreak. The P/Ts provide the case level information required for the centralized collation and analysis of data by the OICC lead agency in order to inform decision-making and draw conclusions based on all available evidence during a multi-jurisdictional food-borne illness outbreak.

6.2   Federal Authorities

At the federal level, PHAC, HC, and CFIA have legislated responsibilities for responding to food-borne illness related events.  The interaction between HC and CFIA are detailed in the “Memorandum of Understanding between Health Canada and the Canadian Food Inspection Agency” of June 1999 and its corresponding framework document entitled “Roles and Responsibilities with respect to Federal Food Safety and Inspection Activities.”  In 2008, a trilateral “Memorandum of Understanding between Health Canada, and the Public Health Agency and The Canadian Food Inspection Agency” was finalized. The trilateral MOU specifies the roles and responsibilities of the CFIA, HC, and PHAC as they relate to the common issues that directly or indirectly have an impact on human health including food safety and nutrition, infectious disease outbreak management, and emerging zoonotic diseases. These MOUs and corresponding Roles and Responsibilities Frameworks reference the FIORP as a key guidance document. The following is a summary of the respective federal responsibilities regarding food-borne illness outbreak response.

6.2.1 Public Health Agency of Canada

Under the leadership of the Chief Public Health Officer, PHAC delivers on the Government of Canada’s commitment to promote and protect the health and safety of all Canadians. Among its activities is responding to multi-jurisdictional infectious disease outbreaks and acting as the National IHR (2005) focal point, the national centre designated to communicate with the World Health Organization (WHO) IHR Contact Points under the regulations.

Within the Government of Canada, the usual first point of contact for notification by the partners of issues related to actual or potential food-borne illness outbreaks and requests for content expertise/support for food-borne outbreak investigation is the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases (CFEZID), within the Infectious Disease Prevention and Control Branch (IDPC) of PHAC. It:

• conducts national surveillance for enteric illnesses;
• provides consultation, content expertise, coordination, and leadership in outbreak investigations;
• coordinates multi-jurisdictional outbreaks involving more than one P/T or country where appropriate;
• interprets and comments on the strength of evidence collected during the epidemiological investigation of food-borne illness outbreaks;
• provides training in outbreak response/investigation methods;
• coordinates and collaborates with international surveillance; and
• manages Enteric Public Health Alerts (Annex 3).

The National Microbiology Laboratory (NML) provides reference services for strain identification and characterization, national laboratory-based surveillance, and dissemination of information through PulseNet Canada and the National Enteric Surveillance Program (NESP) (described in Annex 10). The NML, through PulseNet Canada, is the usual first point of contact for P/Ts sharing strain identification data and the detection of clusters of strains that are occurring in more than one P/T or country, indicating the potential for multi-jurisdictional food-borne outbreaks.

PHAC has public health capacity and resources that can be mobilized to assist in the investigation of food-borne illness outbreaks. Programs include:

The Canadian Field Epidemiology Program (CFEP), in the Office for Public Health Practice, which provides specialized training for health professionals in the practice of applied epidemiology. Field epidemiologists are deployed to assist in field investigations of food-borne illness outbreaks within the jurisdiction of their placement and are mobilised as an Epi-aid to local and P/T public health authorities.  Field epidemiologists may also assist international outbreak investigations.

The Canadian Public Health Service (CPHS) is a program to recruit and deploy qualified staff in consultation with interested health jurisdictions, and to provide these staff with ongoing field experience and training in order to build public health capacity across the country. The CPHS provides public health support to provincial, territorial or local health jurisdictions, and to public-health-oriented NGOs and may be involved in enhancing  routine surveillance and epidemiological work. The CPHS is also prepared to deal with broader public health issues as well as outbreak or pandemic duties as these needs may emerge.

6.2.2 Health Canada

Health Canada (HC) is the federal department responsible for helping Canadians maintain and improve their health. Its food safety responsibilities include:

• the establishment of policies, regulations and standards related to the safety and nutritional quality of all food sold in Canada;
• the regulation of pesticides; and
• the evaluation of the safety of veterinary drugs used in food-producing animals. 

HC also has food safety responsibilities with respect to First Nation communities south of 60º parallel, and food served on common carriers.

HC may be involved or assist with investigations of food-borne illness outbreaks as follows:

The Health Products and Food Branch (HPFB) provides, upon request, health risk assessments on food-related hazards to the Canadian Food Inspection Agency (CFIA) or other stakeholders (e.g. provincial governments).  The Food Directorate within HPFB focuses on issues relating to microbial pathogens, chemical contaminants, food allergens or other potential health hazard in foods; while the Veterinary Drugs Directorate focuses on issues related to veterinary drug residues exceeding the legal limits.

The Food Directorate also provides:

• scientific advice and analytical surge capacity for analyzing microbiological contaminants, chemical contaminants, food additives, food packaging materials and incidental additives, and food allergens in food and clinical samples;
• national reference diagnostic services for food-borne botulism, listeriosis and viruses; and
• risk management advice, including public communication.

The Pesticide Management Regulatory Agency (PMRA) provides, upon request, health risk assessments on pesticide residues exceeding the legal limits to the CFIA or other stakeholders.  It also contributes to investigations involving incidences of pesticide residues above legal limits.

The Healthy Environment and Consumer Safety (HECS) Branch prevents food-borne illness on common carriers (e.g., cruise ships, aircraft, passenger ferries and passenger trains) and their ancillary services (e.g. flight kitchens) through a comprehensive food safety inspection and auditing program.  In addition, HECS investigates suspected water or food-borne illness outbreaks stemming from these conveyances and their ancillary services.

The First Nations and Inuit Health Branch (FNIHB) provides national support and technical advice in the investigation of foodborne diseases for First Nations communities on reserve south of 60º parallel. The Environmental Public Health Division within FNIHB is the national contact point between the First Nations and Inuit Health (FNIH) regional offices (of the Regions and Programs Branch) and other involved parties (e.g., CFIA) to coordinate efforts during a suspected or confirmed food-borne outbreak in First Nations communities. FNIH regional staff disseminates food recall information issued by the CFIA; carries out food safety investigations in food establishments; conducts visits at facilities with vulnerable populations (e.g., daycare, treatment centres, hospitals); and provides public education and food handler training sessions, as needed, in affected First Nations communities.

6.2.3 Canadian Food Inspection Agency

The Canadian Food Inspection Agency (CFIA) delivers all federal inspection and enforcement services related to food under the authority of 13 federal acts that address all stages of the food continuum. Not only does CFIA inspect foods, but also the seed, livestock feed, fertilizers, plants, and animals on which a safe food supply depends.  CFIA’s contribution to the investigation and control of food-borne illness outbreaks includes its food safety investigation, testing and recall activities, as well as its regulatory compliance and enforcement activities.

CFIA’s role in food safety investigations includes tracing foods from the retail level through distribution to production or processing facilities to pinpoint a suspected source of the problem. Information obtained throughout the food safety investigation provides the basis for the assessment of risk and the development of appropriate risk management strategies to control affected products. The food industry carries out most recalls voluntarily. However, if a company is not available or willing to conduct the recall voluntarily, the Minister of Agriculture and Agri-Food can, under the Canadian Food Inspection Agency Act, order a company to recall a product where the Minister believes that it poses a risk to public, animal, or plant health. In the case of voluntary recalls, CFIA officials will verify that the recalling firm has recalled the product effectively.

When a potentially contaminated food has been identified in Canada which could pose a risk to the public, CFIA launches a food safety investigation to:

• determine the nature, extent and cause of the problem;
• confirm whether a health hazard exists; and
• identify the appropriate risk management options.

This work is done collaboratively with P/T partners guided by MOUs.

There are three groups within CFIA that play key roles in the food safety response to food-borne illness outbreak situations:

Regional inspection staff including Area Recall Coordinators (ARCs) are involved in food safety inspection activities.  The ARCs are also the usual first point of contact within CFIA for local/regional health units and P/Ts.

The Office of Food Safety and Recall (OFSR) is responsible for the coordination and consistency of decision-making on food safety issues and recalls. The OFSR is the usual first point of contact for national and international food safety related issues.

The Food Safety Division of the Food Safety and Consumer Protection Directorate is responsible for providing scientific analysis and guidance to CFIA staff as well as providing the link with HC for obtaining health risk assessments as appropriate.

6.3 Other Agencies or Organizations

Expertise from other F/P/T or international agencies may be sought to provide advice in the control of outbreaks caused by unusual pathogens or toxic substances in foods.

If an outbreak is suspected to be related to criminal activity (e.g., tampering and terrorism), law enforcement agencies (local police or the Royal Canadian Mounted Police (RCMP)) assume the responsibility for the law enforcement response and the criminal investigation (Section 7.8.1).

7. OPERATING PROCEDURES

The following sections outline the general operating procedures for coordinating the response to a potential multi-jurisdictional food-borne illness outbreak. Annex 3 provides a contact point for the current FIORP contact list.  Figure 1 provides a schematic representation of how the FIORP operates.

Figure 1- How the FIORP operates

Figure 1 - Text Equivalent

7.1 Notification Between Partners of a Potential Multi-Jurisdictional Food-borne Illness Outbreak

Notification refers to the initial contact between partners to identify an issue with the potential to become a multi-jurisdictional food-borne illness outbreak.

The general pathways for notification used to guide the sharing of information when such an issue is identified are described below in Figure 2. Annex 4 provides a description of Public Health Alerts, which is an effective communication tool used for early notification of possible or confirmed outbreaks with the potential to be multi-jurisdictional among local/regional and F/P/T health officials (some F/P/T agricultural authorities also have access).

The following criteria are indicative of issues with the potential to be or to become multi-jurisdictional food-borne outbreaks. Officials at any level (local, provincial, or federal) should notify their appropriate partners when these criteria are identified to allow a more complete assessment of available information to occur and potential multi-jurisdictional food-borne outbreaks to be identified:

• Illness is spread over more than one geographic jurisdiction (multiple provinces and territories or countries);
• Management of outbreak involves multiple agencies (i.e. public health, agriculture and agri-food, food regulatory, emergency management, etc.);
• An unusual or particularly pathogenic organism is suspected/involved;
• An outbreak is known, or has potential, to be related to a commercially broadly distributed ready-to-eat item;
• A large number of unexplained illnesses are involved;
• Intentional contamination is suspected;
• When the outbreak cannot be controlled; or
• May constitute a public health emergency of international concern as described in the IHR (2005).

The notification of international partners may also be required. The responsible federal partner will act as a liaison with other foreign countries.  In international food-borne illness outbreak situations, PHAC (CFEZID) will act as the main liaison with international public health counterparts. CFIA will act as the main liaison with international food safety counterparts for international food safety related issues.

When an urgent action is required in response to a notification, it is important to recognize that phone calls are preferred over e-mail communication.

Figure 2 - Overview of Notification Pathways (Communication between Partners to identify issues of concern)

Figure 2 - Text Equivalent

7.2  Determination of a Potential Multi-Jurisdictional Food-borne Illness Outbreak

A potential multi-jurisdictional food-borne illness outbreak may come to the attention of public health or food regulatory agencies through: notifications from partners as described in Section 7.1; or through reports of human illness (surveillance); the identification of a food-borne hazard during a routine inspection with the potential to cause human illness; or, a food safety investigation. Examination of surveillance data and the determination of cases in more than one jurisdiction should prompt further investigation and notification of investigative partners.

7.2.1 Human Illness Potentially Linked to Food

Human health surveillance activities occur at the local/regional, F/P/T, and international levels.  Increased or unusual cases of human illness will trigger investigations to determine a common source.  Identification of human illnesses which may potentially be linked to food may originate from the following sources:

• Outbreaks recognized by the local/regional officials through increased reporting of a particular pathogen or complaints of illness linked to a common event or food product;
• Routine surveillance activities at the national or P/T level indicating that a P/T or national outbreak, potentially food-borne in nature, is in progress (e.g. via National Enteric Surveillance Program (NESP) and PulseNet Canada – see Annex 9); and
• International outbreaks possibly linked to food, that could affect Canada may be identified through PHAC’s (i.e. CFEZID or NML) network activities with international groups (e.g., ENTERNET, the U.S. Center for Disease Control and Prevention, PulseNet International, the World Health Organization INFOSAN, media, notification from foreign bodies, etc.).

7.2.2 Identification of a Food-borne Hazard that Could Cause Human Illness

Food safety investigations may be triggered by the following situations:

• Consumer complaints concerning a food, which may involve reports of illness;
• Food processing deviations identified during inspection activities;
• Laboratory reports indicating the presence of a hazardous contaminant (biological or chemical) in a distributed food;
• Notification from industry (manufacturer, processor, distributor, importer, common carrier, etc.) of a potential food safety problem; or
• Information about a food safety problem from other external sources (e.g., foreign health officials, industry or public health associations, academia, etc.).

7.3 Initial Assessment/Review of Information and Activation of the Outbreak Investigation Coordinating Committee (OICC)

Once a potential multi-jurisdictional food-borne illness outbreak has come to the attention of public health or food regulatory agencies, there is a requirement to examine the current available information and determine if it is sufficient to indicate the presence of a potential multi-jurisdictional food-borne illness outbreak that requires a collaborative and coordinated investigation and the activation of an OICC (described in section 7.4).

A teleconference call will be held among affected partners (those with cases of human illness or having relevant food-borne hazard information) to review the available information and assess whether or not an OICC is required and should be activated.

The FIORP OICC should be activated when the investigation and response to the identified potential multi-jurisdictional food-borne illness outbreak:

• involves or may involve cases occurring in multiple P/Ts or countries and any of the following:
  • provides reasonable probability that the outbreak is associated with food (other potential sources to explain enteric illness increases e.g. travel have been ruled out or a food-borne hazard with the potential to be linked to illnesses has been identified);
  • is known or has the potential to be related to a widely-distributed food product;
  • involves or has the potential to involve multiple agencies; and/or
  • requires or will benefit from the use of the FIORP to enhance mitigation of the outbreak through collaboration, sharing of information and planning and coordinating actions and communications.

An identified food-borne hazard in the absence of human illness or widespread injury would not trigger OICC activation. When, a potentially contaminated food has been identified in Canada which could pose a risk to the public, CFIA will launch a food safety investigation (Section 6.2.3).

The severity and scope of the identified potential multi-jurisdictional food-borne illness outbreak may further support the requirement for and activation of an OICC if, for example, any of the following exist:

• large numbers of unexplained cases (above expected values);
• rapidly increasing case count (new cases continue to be identified);
• severe illness or deaths observed among identified cases;
• an unusual or particularly pathogenic organism is suspected/involved; and/or
• a vulnerable population is over-represented among cases (e.g. all children).

When the initial assessment and review of available information indicates that an OICC is required and should be activated, the FIORP duty officers (Section 7.4.2.4) will be notified by the OICC lead (Section 7.4.2.2) and asked to inform their senior officials and the OICC lead will initiate a teleconference call with the affected partners’ identified representatives to activate the OICC and begin the coordination of the investigation.

Any partner involved in an epidemiological or food safety investigation where evidence exists to show a food product is the cause, or has the potential to be the cause, of a multi-jurisdictional outbreak can request that the OICC be established under the leadership described below. Where conflicts arise over the need for the OICC to be established, these should be discussed with the FIORP duty officers representing the affected partners so that guidance from senior officials can be sought.

7.4 Outbreak Investigation Coordinating Committee (OICC)

Identifying the source of a multi-jurisdictional food-borne illness outbreak represents a collaborative effort between local, provincial, and federal agencies where sharing of information between public health and food regulatory agencies is critical to the investigation’s effectiveness in removing the source of risk to the public.

A central element of the FIORP is the establishment of an Outbreak Investigation Coordinating Committee (OICC), with representation from the partners active in a specific outbreak, to coordinate a multi-agency response to a food-borne illness outbreak in Canada.

7.4.1 Purpose of the OICC

The purpose of the OICC is to allow the partners to use the FIORP as a guide to share information and to formulate and coordinate the outbreak investigation and response strategies in order to mitigate or contain the effects of multi-jurisdictional food-borne illness outbreaks in a timely and effective manner, thereby protecting the health of Canadians.

The OICC’s primary objectives are to:

• facilitate communications among participating organizations;
• clarify roles and responsibilities specific to the incident at hand;
• serve as a central point to share information from all sources and discuss findings including results of centralized data analysis (centralized collation and analysis of data is the responsibility of the OICC lead);
• communicate outbreak response strategies and coordinate investigations among the partners, such as follow-up and corrective actions;
• identify resource needs and opportunities for sharing resources;
• establish priorities for response where critical resources are limited or constrained;
• gain consensus in resolving issues that emerge; and
• develop comprehensive communications strategies and harmonize external communications and to ensure the release of consistent and complementary messages to the public and other stakeholders (see Annex 12).

7.4.1.1 Decision-Making and Resolving Differences of Opinion

The purpose of the OICC is to effectively respond to multi-jurisdictional food-borne illness outbreaks by coordinating a unified response to the health risk. This requires the OICC to make consensus-based decisions to develop coordinated strategies. While the OICC will strive to reach consensus to guide response actions, the OICC partners recognize that each partner has unique legal obligations, policies, and mandates that must be respected. Any decisions made by one of the partners pursuant to its obligations, but related to the purpose of the OICC should be communicated to all OICC members.

The OICC will attempt to resolve all differences of opinion during the course of an outbreak. However, when consensus cannot be reached, the partners should seek guidance from senior officials in their respective agencies through their identified FIORP duty officer (Section 7.4.2.4). Any decision made by senior officials in resolving the issue should be communicated to all OICC partners.

OICC collaboration includes:

Section 7.5: Coordinated Investigations
Section 7.6: Integrated Analysis
Section 7.7: Risk Assessment
Section 7.8: Public Health and Food Safety Actions
Section 7.9: Communication with the Public
Section 7.10: Outbreak Conclusion
Section 7.11: Outbreak Debrief/Review

7.4.2 Outbreak Investigation Coordinating Committee (OICC)

7.4.2.1 Composition of the OICC

An OICC will be comprised of representatives designated to act on behalf of the partners involved in the food-borne illness outbreak investigation. It is the responsibility of each of the partners to determine their own appropriate representation on the OICC. The partners should strive to limit representation on the OICC to the responsible parties required for investigation and response to the multi-jurisdictional food-borne illness outbreak.

The composition of the OICC will depend on the nature of the outbreak, and it may evolve as knowledge related to the source of the outbreak is generated during the outbreak. At varying times, it should have representatives that provide epidemiological, food safety, laboratory, and communication expertise from the different levels of government required.
Members may include:

• PHAC;
• CFIA:
• HC;
• Provincial/territorial partners;
• Local public health units; and
• Other agencies such as RCMP and emergency response agencies as required.

7.4.2.2 Determination of the OICC Lead

The lead organization responsible for coordinating an OICC (OICC lead) is identified using these guidelines:

• If an outbreak involves more than one P/T or has an international dimension (more than one country), PHAC (CFEZID) will be considered the OICC lead.
• PHAC (CFEZID) may defer the OICC lead to a P/T upon agreement by all OICC representatives, should an outbreak occur primarily within that province or territory, and a formal outbreak investigation team has already been established.

Any partner may request that an OICC be activated under the leadership described above.

Where an individual province/territory has a food-borne illness outbreak response protocol, it will guide outbreak investigation within that province/territory. The FIORP may also be used by a P/T to guide investigation and response if the outbreak is limited to a single province/territory, where a food-borne illness outbreak response protocol does not exist.

If the FIORP is used by a P/T to guide investigation and response to a food-borne illness outbreak and the outbreak is contained within the single P/T, the affected P/T would be considered the OICC lead.

7.4.2.3 Responsibilities of the OICC Lead

The OICC lead will be responsible for contacting all the FIORP duty officers (Section 7.4.2.4) of participating organizations to inform them that an OICC has been established and for ensuring that these representatives receive summaries of OICC activities and actions. The FIORP duty officers will be responsible for sharing these with senior officials within their respective organizations.

Responsibilities of the OICC lead will also include centralized collation and analysis of data, managing meetings, recording and distributing discussion summaries and action items, and maintaining documentation of the response effort.

The OICC teleconference calls/meetings are chaired by an individual identified by the OICC lead. The chair may change as the outbreak evolves.

The OICC will be dismantled once the outbreak is declared to be resolved. It is the responsibility of the OICC lead organization to advise other representatives that the OICC has been dismantled.

7.4.2.4 FIORP Duty Officers

Each partner will appoint a primary designated representative – the FIORP duty officer (by named position within their respective organization) who will be responsible for briefing senior officials within their organization and ensuring that their respective jurisdiction leads or participates in an OICC as required. The FIORP duty officers will be notified by the OICC lead when an OICC is established with participation by their organization and will be responsible for notifying  and providing regular updates to their senior officials. Contact information for the FIORP duty officers will be maintained as part of the FIORP contact list.

7.5 Coordinated Investigations

7.5.1 Epidemiological Investigations

To facilitate epidemiological investigations of multi-jurisdictional food-borne illness outbreaks, the OICC will assess what information is required and determine which partner is best able to gather the identified information. Every effort will be made to standardize the collected information. Data analysis will occur within each jurisdiction and agency as per standard protocol. However, when multiple partners are involved, the overall collation and analysis of epidemiological data will take place within the identified OICC lead. This analysis will support the examination of findings from all aspects of the outbreak investigation. This information will be shared as described in the Guiding Principles (section 5 v.).

When human illness is recorded in more than one P/T with a potential link to a food source, or there is exposure to a common food distributed to more than one P/T, the OICC lead will coordinate the epidemiological investigation. This investigation will be conducted in collaboration with the affected partners. In international food-borne illness outbreak situations, PHAC (CFEZID) will act as the main liaison with international public health counterparts.

7.5.2 Food Safety Investigations

When the source of an outbreak is suspected to be a food, a food safety investigation will be conducted to determine whether the food may be responsible for the outbreak and to strive to identify the root cause of the contamination in the affected food. 

If the food is imported or shipped inter-provincially or manufactured in an establishment under CFIA's jurisdiction, the CFIA will conduct the food safety investigation.

When a food product is produced or manufactured in a facility that received a licence or registration from a P/T or regional/local authority, or where CFIA has signed an MOU with a P/T concerning shared responsibilities for inspection, the appropriate regulatory officials will conduct the food safety investigation and may request assistance from other regulatory partners.

Should the food safety investigation expand to include issues of employee health, where employee records of illness and/or employee test results are required, the responsible regulatory officials should request the assistance of the appropriate public health authority in the jurisdiction of the investigated facility.

7.5.3 Laboratory Investigations

Both epidemiological and food safety investigations usually involve laboratory testing.  Each of the partners is responsible for conducting the appropriate laboratory analyses as part of their respective investigations and mandates.  If an OICC is in place, it will coordinate laboratory analyses in order to avoid overlap and duplication, permit discussion of issues, and share results.

In some cases the lead partner may not have the necessary capacity or expertise to perform the necessary test(s). It should then contact supporting laboratories (refer to Annex 10 for detailed guidance on laboratory capability and instructions for access) in order to send the samples to a laboratory which has the required expertise and capacity.

The use of PulseNet or other existing laboratory networks should facilitate communication among F/P/T laboratories.

If Clostridium botulinum is suspected, clinical, food, and environmental samples should be sent directly to the Botulism Reference Service as per the instructions outlined in Annex 5, unless botulism testing is available within the P/T.

If Listeria monocytogenes is suspected, clinical, food, and environmental samples should be sent directly to the Listeria Reference Service as per instructions outlined in Annex 6, unless Listeria testing is available within the P/T.

7.6 Centralized Integrated Analysis

When multiple partners are involved, centralized collation and analysis of data by the OICC lead agency is required to inform decision-making and draw conclusions based on all available data. Findings from the epidemiological, laboratory, and food safety investigations will be shared with the partner members of the OICC and integrated to identify the potential cause and source of the outbreak and areas for further investigation.

7.7 Health Risk Assessment (HRA)

HC and the CFIA have the federal responsibilities for food safety.  An appendix to the Memorandum of Understanding (MOU) between HC and the CFIA on Food Safety Emergency Response (dated May 2000) describes the roles and responsibilities of each party with respect to the management of the federal food safety system. Where no standard or guideline exists, or where the standard, policy or guideline does not provide an indication of the appropriate control expected to have adequate health protection relative to the identified health concern, HC is responsible for conducting a health risk assessment (HRA), upon request, to the CFIA or other stakeholders (e.g. provincial governments).

HC science-based health risk assessments are completed in a rapid and timely manner in order to ensure that appropriate risk management decisions are taken to prevent contaminated food from reaching the consumer.  Data gathered through the centralized integrated analysis is considered in the HRA for the determination of the level of risk posed by a food. The HC HRA process follows the guidelines developed by the FAO/WHO Codex Alimentarius Commission 14, which is responsible for developing international food standards and guidelines. Decisions and rationales are conveyed to the requesting inspection authorities who depend on such assessments, and are also shared with the OICC to facilitate its coordination role. HC representation on the OICC ensures that the necessary background and information is provided to support the health risk assessment process.

7.8 Public Health and Food Safety Actions

Actions undertaken during a food-borne illness outbreak to address the source of the outbreak and prevent further cases of human illness may include a wide range of activities by one or more of the partners. Examples include:

• recall of a commercially prepared food;
• detaining a product;
• disposing of contaminated or suspected foods;
• public communication outlining recommended prevention and control activities and raising awareness through communication with vulnerable populations;
• case and contact management;
• prevention and control measures; and
• provision of prophylaxis (e.g. vaccination for HepA contacts).

Each partner will conduct the necessary mitigation actions under its respective mandate. The OICC coordinates information-sharing related to these actions. The OICC will also facilitate discussions concerning the timing of actions by multiple partners.

7.8.1 Tampering and Terrorism

In the event that a multi-jurisdictional food-borne illness outbreak investigation identifies or suspects the intentional contamination of a food product, the appropriate local/regional law enforcement agency shall be immediately notified.  Regardless of police jurisdiction, the RCMP National Operations Centre must also be contacted at 613-993-4460.

Following notification of the appropriate authorities, the food safety and epidemiological investigations will continue to be carried out in collaboration with law enforcement authorities, who may conduct a criminal investigation. The partners involved in the food-borne illness epidemiological and food safety investigations would continue to collaborate while informing their respective law enforcement officials.

7.8.2 Exchange of Industry Information

a) Exchange of Information with Industry

During an investigation, all implicated companies will be kept informed of developments by the responsible inspection authority.

The CFIA is the responsible inspection authority and primary contact with processors and importers operating under federal jurisdiction.  However, for processors operating under P/T jurisdiction or where CFIA has signed an MOU with a P/T concerning shared responsibilities for inspections, the appropriate P/T officials would be the primary industry contact.

Some outbreaks may require communication with industry representatives beyond the implicated facility. In this case, the OICC will identify the lead communicator, according to the partners' mandates and jurisdictions.

b) Exchange of Industry Information between OICC partners

The responsible inspection authority will share relevant information stemming from their investigation with other investigating organizations through the OICC, as appropriate. The exchange of information among government agencies will be conducted according to applicable provincial and/or federal access to information and privacy legislation, and existing information-sharing agreements. Confidential business information provided by industry will be treated accordingly.

7.9 Communication with the Public

7.9.1 Responsibility

Each of the partners has the responsibility to communicate with the general public, including those at greater risk, within its respective jurisdiction and to designate a spokesperson (see Annex 11).

Due to the nature of food-borne illness outbreaks, all involved partners have a responsibility to ensure communications activities are coordinated in a consistent and timely way.

Communications staff develop products with input from content experts. Further details about responsibilities are provided in Annex 11, Guidelines for Communicating with the Public and Those at Greater Risk. Table 1 of the Annex defines which organization leads certain communication activities during food-borne illness outbreaks that are restricted to a single P/T, span more than one P/T or country, or are occurring on common carriers (e.g., cruise ships, aircraft, passenger ferries and passenger trains) and international vessels (i.e. cargo vessels) entering into Canada.

Communication to health professionals may also be required as part of the response to a multi-jurisdictional food-borne outbreak. This communication will be coordinated as part of the OICC investigation and response activities. Distribution of the communication products to healthcare professionals remains the responsibility of the P/Ts. 

7.9.2 Public Communications Activities and Content

Public communications activities and content in the event of a food-borne illness outbreak will be guided by several key objectives:

• to engage in timely and appropriate communications activities coordinated among all partners;
• to reach the general public and those at greater risk;
• to ensure the communications response reflects general risk communications, and emergency and crisis communications principles;
• to develop consistent and complementary communications products in a timely manner;
• to develop relationships and information-sharing processes among communications staff of involved partners; and
• to ensure surge capacity and after-hours availability of communications/media relations staff of the involved partners during an outbreak.

The Communications Directorate of the Public Health Agency of Canada will provide an evaluation of communications activities to assess effectiveness.

Annex 11, Guidelines for Communicating with the Public and Those at Greater Risk, provides a framework for public communications activities of the involved partners.

7.10 Outbreak Conclusion

The OICC will evaluate all available evidence describing the progression of the outbreak in order to determine when response efforts can be concluded. The OICC lead should continue to monitor for ongoing cases that may need to be investigated for a period of time following the dissolution of the OICC to determine if they can be attributed to a particular source.

After reviewing the status of the food-borne illness outbreak, the OICC lead, in consultation with the OICC, will declare the outbreak investigation closed. The OICC will then be dismantled and the participating agencies may demobilize resources. OICC members will also collectively inform stakeholders of the conclusion of the OICC.

The OICC lead, with the assistance of agencies represented on the OICC, may prepare and circulate an outbreak summary or final report to chronicle key events and findings from the outbreak investigation.

7.11 Outbreak Debrief/Review

Post outbreak reviews may be conducted at the request of the OICC lead or any of the partners involved in the response.  For a large outbreak involving multiple partners, a formal debriefing meeting is recommended and should be chaired by the OICC lead.

The goals of the post outbreak review should include, but are not limited to:

• confirmation of the outbreak cause;
• identification of a method to prevent a reocurrence;
• assessment of the effectiveness of outbreak control measures and any difficulties met in implementing the control measures;
• identification of the long-term measures to prevent reoccurence, such as new or revised policies or standards;
• evaluation of the collaborative response efforts, including communication and coordination between jurisdictions;
• clarification of resources, structural changes, or training needs to optimize future responses;
• identification of the necessary improvements or adjustments to the FIORP. Any recommendations to that effect should be provided to the contact identified in the FIORP Contact section;
• discussion of any legal issues which may have arisen; and
• assessment of a need for further scientific studies.

The outbreak debrief/reviews should be conducted in a timely manner after the resolution of the outbreak in order to benefit from the lessons learned.  Unless otherwise agreed upon by the partners, the OICC lead will chair the outbreak debrief/review. It is the chair’s responsibility to provide a summary report to all other partners.  The partners may also further distribute the report to other officials within their organizations who would benefit from the information.

Annex 12 provides a list of questions to be addressed during the outbreak/debrief process.

8. ADMINISTRATIVE REVIEW

PHAC will be the custodian of the FIORP.  Under PHAC’s leadership, the FIORP will be reviewed regularly to ensure the accuracy of organizational names, roles and responsibilities, and to assess the recommendations received through the post outbreak reviews.  Smaller scale revisions will occur as necessary to address these identified issues and to maintain up-to-date information regarding MOUs and information-sharing agreements as they are developed.

PHAC will also update the contact list quarterly based on input from those on the list and any changes provided by the partners will be made upon receipt.

A more formal review process will occur every five years to ensure the document is up-to-date and will be created with F/P/T input. A F/P/T body will be identified to perform this task.

9. EMERGENCY OPERATIONS CENTRE (EOC)
ACTIVATION AND INCIDENT COMMAND SYSTEM (ICS)

Most multi-jurisdictional food-borne illness outbreak investigations do not require the use of an incident command system (ICS) and activation of emergency operations centres (EOCs).

However, agencies may consider using such an approach for some public health emergencies, including food-borne illness outbreaks, to help coordinate the response. Agencies that are implementing an ICS will determine the types of events or outbreaks that will trigger the use of such a system.

If an ICS is to be used, it should be incorporated into the agency's food-borne illness outbreak response protocol. In relation to food-borne illness events, all the partners are responsible to notify other partners of their intent to utilize ICS and activate their respective EOC(s).

10. SUPPORTING DOCUMENTS/REFERENCES

1. Food Emergency Response Manual.  The Canadian Food Inspection Agency, 59 Camelot Drive, Nepean, Ontario, Canada, K1A 0Y9. (available by contacting the CFIA’s Office of Food Safety and Recall)
2. Compendium of Analytical Methods - Volumes 1 to 4. 1998. Polyscience Publications, P.O. Box 148, Morin Heights, Quebec, Canada J0H 1H0. Tel: (514) 226-5870 fax: (514) 226-5866.
3. (available at: http://www.hc-sc.gc.ca/food-aliment/mh-dm/mhe-dme/compendium/e_index.html)
4. Procedures to Investigate Foodborne Illness, Fifth Edition - 1999.  International Association of for Food Protection, 6200 Aurora Avenue, Suite 200 W, Des Moines, Iowa 50322-2863, USA.
5. (available through: http://www.foodprotection.org/imageup/Booklet%20Order%20Form.pdf)
6. Cruise Ship Inspection Program, 2004, Workplace Health and Public Safety Programme, Health Canada
7. (available upon request from: phb_bsp@hc-sc.gc.ca)
8. The Council to Improve Foodborne Outbreak Response (CIFOR), Guidelines for Foodborne Disease Outbreak Response: www.cifor.us/documents/CIFORGuidelinesforFoodborneDiseaseOutbreakResponse.pdf
9. British Columbia Foodborne Illness Outbreak Response Protocol
10. Alberta Foodborne Illness and Risk Investigation Protocol, Revised Jan 15, 2010
11. Ontario Foodborne Health Hazards and Illness Outbreak Investigations Memorandum of Understanding
12. Nova Scotia Guidelines for Outbreak Management (January 2010)
13. Manitoba Enteric Illness Protocol (March 2008)
14. FAO/WHO CODEX reference document: Principles and guidelines for the conduct of microbiological risk assessment, CAC/GL-30 (1999)

11. LIST OF ACRONYMS

• ARC: Area Recall Coordinators (CFIA)
• CFIA: Canadian Food Inspection Agency
• CFEZID: Centre for Food-borne, Environmental and Zoonotic Infectious Diseases (PHAC)
• FMCE: Food Microbiology and Chemical Evaluation (CFIA)
• F/P/T: Federal/Provincial/Territorial
• HACCP: Hazard Analysis Critical Control Points
• HC: Health Canada
• HECSB: Healthy Environment and Consumer Safety Branch (HC)
• IDEP: Infectious Disease and Emergency Preparedness Branch (PHAC)
• MOU: Memorandum of Understanding
• NESP: National Enteric Surveillance Program (PHAC)
• NML: National Microbiology Laboratory (PHAC)
• OFSR: Office of Food Safety and Recall (CFIA)
• OICC: Outbreak Investigation Coordination Committee
• PHAC: Public Health Agency of Canada
• PMRA: Pest Management Regulatory Agency (HC)
• P/T: Provincial/Territorial or province/territory
• RCMP: Royal Canadian Mounted Police
• WHPSP: Workplace Health and Public Safety Programme (HC)

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¹ International Health Regulations (2005), Resolution 58.3 of the 58th World Health Assembly, 23 May 2005, online: http://www.who.int/gb/ebwha/pdf_files/WHA58/A58_55-en.pdf