Listeriosis: What happened with Maple Leaf

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Listeriosis What happened with Maple Leaf
Quebec Cheese? 

• Eleni Galanis and Sion Shyng
• BC Centre for Disease Control
• BCFPA
• Oct 9 2008

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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

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What are Listeria and listeriosis?
www.nrc-cnrc.gc.ca
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Some definitions

• Listeria bacterium
• Listeria monocytogenes (LM) species pathogenic
  to humans
• Listeriosis illness caused by Listeria

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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

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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 Farber et al Microbio Rev 1991
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Listeria growth

• Listeria tend to multiply at refrigerator
  temperatures

• LM grew from gt 1 food item in fridge of 64 of
  listeriosis cases1
• 11 of food specimens in fridge of cases
  contained LM1

1 Pinner et al JAMA 1992
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How do Listeria make us sick?

• Ingestion
• Incubation 10-70d (average 31d)
• Gastrointestinal infection
• Invasion into blood stream
• Dissemination to organs
• Neurological system
• Placenta

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Clinical presentation and treatment
Isolation site, cases of listeriosis, BC 2002-06
(N59)

• Bacteremia / sepsis
• Meningitis
• Antibiotic treatment
• Death 20-50

Deeks et al CCDR 2005
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Who is most at risk?

• Individuals with weakened immune systems (e.g.
  cancer, transplant recipients, people on
  corticosteroids)
• Elderly
• Pregnant women
• Neonates

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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

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Cases of invasive listeriosisBC, 1997-2008
(N100)
As of Oct 8 2008
BCCDC 2008
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Listeriosis by age and sex BC, 2002-07 (N67)
BCCDC 2008
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2008 Canadian outbreak associated with Maple Leaf
meat Epidemiology
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Agencies involved in investigation
Health Canada
CFIA
Maple Leaf
CFIA BC
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What happened when?
ON outbreak in nursing homes
July
Sep
1 5 10 15 20 25
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August
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Cases of listeriosis in the ML outbreak
Province Cases confirmed to be part of the outbreak Cases suspected to be part of the outbreak
Ontario 40 4
BC 5 3
Other 8 3
Total 53 10
as of Oct 8 2008 PHAC 2008
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Deaths among cases of listeriosis in the ML
outbreak
Province Deaths where listeriosis was a cause of death Other deaths
Ontario 15 1
BC 2 0
Other 3 2
Total 20 3
Case-fatality43
as of Oct 8 2008 PHAC 2008
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Cases of listeriosis by week of onset, ML
outbreak, 2008 (N52)
Recalls
as of Oct 3 2008 PHAC 2008 and BCCDC 2008
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BC cases (N5)

• 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

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What was the source of the outbreak?

• Which product(s)?
• What time frame?

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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

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Periods at risk
Recalls
Incubation periods
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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

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First Maple Leaf Recall
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BCs 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?

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Expanded Recall(23 Products from Lines 8 9)
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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

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Aug 22, 2008
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3rd Maple Leaf Recall(ALL Products from Est. 97B)
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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

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RHA Actions

• gt7100 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

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• Highlights
• FHA
• Multiple forms of contact
• Information for daycares to distribute to parents
• 100 staff mobilize
• 4 full days

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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

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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.

Source http//www.inspection.gc.ca/english/corpaf
fr/recarapp/2008/2008listrese.shtml
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Source http//www.mapleleafaction.com/plant_clean
ing_en.html
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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.

Oct 9th 4 of 2700 samples positive Lm source(s)
identified?
Source http//www.inspection.gc.ca/english/corpaf
fr/recarapp/2008/2008listrese.shtml
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First Quebec Cheese Recall
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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

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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

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Listeriosis Linked to Cheeses

• 22 cases
• 1 death
• 7 pregnant women
• 6 premature deliveries
• 1 stillbirth
• Cheese at 300 retailers discarded (cross
  contamination potential)

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Salmonella Linked to Cheese

• Fromages La Chaudiere
• Unripened cheese
• Salmonella enteritidis
• 87 cases
• 1 death

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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 Lactée
• recalled 6 cheeses
• "inadequate pasteurization, not linked to
  listeriosis

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BCs Experience

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

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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 (n382)
• 2 Lm positive!

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Health Hazard Alerts

• August 2008
• August 30 - HEALTH HAZARD ALERT - Certain KING
  BEAN WHOLESALERS SANDWICHES may contain Listeria
  monocytogenes
• August 29 - HEALTH HAZARD ALERT - Various fresh
  cheeses manufactured by FROMAGES LA CHAUDIÈRE may
  be contaminated with Salmonella
• August 29 - HEALTH HAZARD ALERT - Certain
  ready-to-eat deli meats sold by CO-OP ATLANTIC
  stores may contain Listeria monocytogenes
• August 29 - HEALTH HAZARD ALERT - Certain
  Kielbassa sausage sold at COUNTRY TRADITIONS,
  TASTE OF COUNTRY, and COUNTRY FARM supply stores
  may contain Listeria monocytogenes
• August 29 - HEALTH HAZARD ALERT - Certain
  sandwiches sold at SAFEWAY STORES may contain
  Listeria monocytogenes
• August 29 - HEALTH HAZARD ALERT - Reduced cold
  cut ends sold by METRO ONTARIO INC. may contain
  Listeria monocytogenes
• August 29 - UPDATED HEALTH HAZARD ALERT - Certain
  ready-to-eat deli meat products may contain
  Listeria monocytogenes
• August 29 - HEALTH HAZARD ALERT - Certain
  ready-to-eat deli meats sold by METRO-RICHELIEU
  STORES may contain Listeria monocytogenes
• August 28 - HEALTH HAZARD ALERT - Certain
  ready-to-eat deli meat products may contain
  Listeria monocytogenes
• August 28 - HEALTH HAZARD ALERT - Certain
  sandwiches sold by LOBLAW COMPANIES may contain
  Listeria monocytogenes
• August 28 - HEALTH HAZARD ALERT - BIG GLEN
  SANDWICH may contain Listeria monocytogenes
• August 28 - HEALTH HAZARD ALERT - Certain
  ready-to-eat deli meats sold by DELTA COUNTRY
  MARKET, DELTA may contain Listeria monocytogenes
• August 28 - HEALTH HAZARD ALERT - Oven roasted
  turkey breast sold by WHITE HOUSE MEATS INC.,
  Toronto may contain Listeria monocytogenes
• August 28 - EXPANDED HEALTH HAZARD ALERT - Cooked
  ham and salami sandwiches and deli lunch box
  wraps sold in SOBEYS, FOODLAND and IGA stores in
  Ontario may contain Listeria monocytogenes
• August 28 - HEALTH HAZARD ALERT - Présence
  possible de la Fromage Tomme de Grosse-Île vendu
  chez S. Bourrassa (Saint-Sauveur) ltée à ne pas
  consommer - Le ministère de l'Agriculture, des
  Pêcheries et de l'Alimentation (MAPAQ)
• August 27 - HEALTH HAZARD ALERT - Cooked ham and
  salami sandwiches sold in SOBEYS, FOODLAND and
  IGA stores in Ontario may contain Listeria
  monocytogenes
• August 27 - Certain KIRKLAND SIGNATURE brand
  platters may contain Listeria monocytogenes
• August 26 - HEALTH HAZARD ALERT - Certain IRVING,
  SUB DELICIOUS, and NEEDS brand sandwiches may
  contain Listeria monocytogenes

• 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 LACTÉE INC.
  may be contaminated by pathogenic bacteria
• September 19 - HEALTH HAZARD ALERT - Présence de
  Listeria monocytogenes - Fromages à ne pas
  consommer - Le ministère de l'Agriculture, des
  Pêcheries 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 ministère de
  l'Agriculture, des Pêcheries et de l'Alimentation
  (MAPAQ)
• September 9 - HEALTH HAZARD ALERT - Présence de
  Listeria monocytogenes - Fromages à ne pas
  consommer - Le ministère de l'Agriculture, des
  Pêcheries 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 ministère de
  l'Agriculture, des Pêcheries 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 - Présence de
  Listeria monocytogenes - Le ministère de
  l'Agriculture, des Pêcheries 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 à ne pas
  consommer - Le ministère de l'Agriculture, des
  Pêcheries et de l'Alimentation (MAPAQ)

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The Ripple Effect

• Policies
• Regulatory Agencies
• Industry
• HACCP
• Industry
• Risk Assessment
• Serving high risk populations

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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

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• Questions?