March 30, 1999
To:Board of Health
From:Dr. Sheela V. Basrur, Medical Officer of Health
Subject:Update on the Recommendations made from the Cyclospora Outbreak of
Spring1998
Purpose:
To inform the Board on Health of the status of the recommendations made in the October 1,
1998 Board of Health Report on the Cyclospora Outbreak in Spring 1998.
Source of Funds:
Not applicable
Recommendation:
It is recommended that the Board of Health continue to request that the Canadian Food
Inspection Agency not allow Guatemalan raspberries to be brought into Canada until they
have been shown to be contamination-free.
Background:
At its meeting on October 13, 1998, the Board of Health endorsed the 19 recommendations
made by Toronto Public Health with respect to the spring 1998 outbreak of Cyclospora (see
Appendix1). The Board of Health also adopted a 20th recommendation that "The Canadian
Food Inspection Agency be requested not to allow Guatemalan raspberries to be brought into
Canada until they have been shown to be contamination-free."
This report provides an update on the status of the major issues identified.
Importation of Guatemalan Raspberries
In September 1998 the Canadian Food Inspection Agency (CFIA), in collaboration with
Health Canada, restricted the importation of Guatemalan raspberries from the 1998 fall
harvest until such time that a team of representatives from the relevant federal agencies made
a visit to audit the Guatemalan farms.
On January 25, 1999 the CFIA announced that they were extending the restriction on
importation of Guatemalan raspberries until further notice. This announcement was made
following a site visit to Guatemala in late November 1998 (see Appendix 2). During this visit
CFIA and Health Canada officials recommended improvements to Guatemalan production
and inspection systems. The CFIA will review the import restriction when Guatemala
implements the recommended improvements. The CFIA advises that if Guatemala can
document the ability to produce Cyclospora-free raspberries, the CFIA will visit the country to
assess their enhanced policy in effect during peak production in April and May prior to
considering any importation. As the Guatemalan growing season ends in late May/early June,
it is unlikely that Guatemalan raspberries will be in the Canadian retail market this spring, the
season of the year for previous Ontario outbreaks of cyclosporiasis (1996 to 1998). A CFIA
border alert is currently in effect to ensure that no Guatemalan raspberries enter Canada and
wholesalers, retailers and distributors have been contacted about the extended restrictions.
Currently, the Food and Drug Administration (FDA) in the United States does not permit
importation of Guatemalan raspberries into the U.S. They will allow a limited importation of
Guatemalan raspberries this spring under a Model Plan of Excellence (MPE) program. A site
visit to Guatemala is planned during the month of March, 1999 to ascertain whether any farms
comply with the MPE requirements and other specific recommendations made by the FDA
following their visit to Guatemalan farms in November 1998.
The MPE involves the implementation of Good Management Practices in farms and exporter
plants and monitoring the system during the picking, classification, packaging and
transportation. Farms and exporter plants that meet the criteria of the MPE are classified as
low risk.
Reportability of Cyclospora Infection
Currently Cyclospora infection is not classified as a reportable disease in Ontario. However,
on November 27, 1998 the Provincial Advisory Committee on Communicable Diseases
(ACCD), which reports to the Minister of Health, unanimously recommended that Cyclospora
infection be listed as a reportable disease under the Health Protection and Promotion Act. It is
expected that the Minister will accept the recommendation from ACCD, at which point
physicians in Ontario and all operators of laboratories which have parasitological diagnostic
capability will be notified of the reportability of Cyclospora infection.
Health Canada has made Cyclospora a nationally notifiable disease. At the October 1998
meeting of the Advisory Committee on Epidemiology, it was recommended that
cyclosporiasis be made a disease under national surveillance. As some provinces may have to
change their legislation, it is conceivable that national surveillance of cyclosporiasis will
commence January 1, 2000.
Laboratory Detection of Cyclospora
While Cyclospora infection is not reportable at this time, the Central Public Health Laboratory
(CPHL) does routinely test stool specimens for Cyclospora oocysts when the specimens are
submitted for parasitology. From August 1, 1998 to March 11th, 1999 there have been five
sporadic cases of Cyclospora identified in Ontario at the CPHL, two of whom resided in the
City of Toronto. This is within the normal expected range for this time period.
While laboratories are able to isolate Cyclospora oocysts from stool specimens, isolation of
Cyclospora from raspberries is virtually impossible. Health Canada's Food Directorate has
been conducting research in Cyclospora isolation and detection methods in food, including
berries, during the past three years. They will be publishing new laboratory procedures
regarding the isolation and identification of Cyclospora oocysts from berries in April 1999.
Food Safety
The CFIA and Health Canada's Laboratory Centre for Disease Control (LCDC) and Food
Directorate are developing a detailed risk assessment of the Cyclospora issue to evaluate the
state of our current understanding of this parasite, its transmission through food and to
identify information gaps requiring further research. Guatemala's system for raspberry
production, inspection and export is also being examined.
A comprehensive foodborne outbreak investigation protocol is being developed
collaboratively by the CFIA and Health Canada's LCDC and Food Directorate. The protocol
describes the roles and responsibilities of each organization involved in the investigation and
control of outbreaks. The document has been presented to the Federal-Provincial-Territorial
Committee on Food Safety for discussion. The Ontario Ministry of Health circulated the
document to municipal representatives, including Dr. Barbara Yaffe of Toronto Public Health,
for comment. Comments will be incorporated into the protocol prior to recirculation. Toronto
Public Health will continue to be involved.
The CFIA is also active in national and provincial initiatives for food safety. The Canadian
Horticultural Council and the Canadian Marketing Association are currently involved in the
development of programs for the hygienic production of fresh produce within the Canadian
On-Farm Food Safety Program. The CFIA also recently presented the "Discussion Paper on
the Proposed Draft Code of Hygienic Practice for Primary Production, Harvesting, and
Packaging of Fresh Produce" to the Codex Committee on Food Hygiene. The paper was well
received and the Committee recommended the development of an International Code of
Practice for the next meeting in October 1999.
Food Safety initiatives are also occurring at the provincial level. The Ontario Food Safety
System (OFSS) is a co-operative effort between the Ministry of Agriculture, Food and Rural
Affairs, the Ministry of Health, and the Ministry of Natural Resources to create a dynamic and
responsive food safety strategy throughout the food continuum. Laboratory research and
analysis will be a major component of the OFSS. There are municipal public health
representatives on the committee, including Dr. Monir Taha from Toronto Public Health
(incoming Director of Healthy Environments and Associate Medical Officer of Health).
Food Safety Legislation
The CFIA enforces the food safety provisions of the Food and Drugs Act and requires that
fresh produce be labelled according to the Canadian Agricultural Products Act and the
Consumer Packaging and Labelling Act. These Acts contain provisions for country-of-origin
labelling of fresh produce imported into Canada. Under its legislative renewal initiative, the
CFIA is examining food regulations under its mandate. The recommendations of the Toronto
Board of Health that pertain to this legislation have been forwarded to the task force team
working on this project.
The Ontario Farm Products and Sales Act, enforced by the Ontario Minister of Agriculture,
Food and Rural Affairs, requires country of origin labelling of produce. Ministry of
Agriculture, Food and Rural Affairs staff are currently examining the possibility of cross
appointments with federal and/or municipal staff to visibly increase enforcement of country of
origin labelling regulations.
Conclusions:
Foodborne disease is emerging as a critical public health issue in North America. There are a
number of initiatives at the federal and provincial levels to enhance food safety. Most notably,
the restriction on importation of Guatemalan raspberries has been continued. The Board of
Health should continue to request that the Canadian Food Inspection Agency not allow
Guatemalan raspberries to be brought into Canada until they have been shown to be
contamination-free.
Contact:
Dr. Barbara Yaffe,
Director, Communicable Disease Control and
Associate Medical Officer of Health,
Toronto Public Health
Tel:(416) 392-7405
Fax:(416) 392-0713
Dr. Sheela V. Basrur
Medical Officer of Health
Attach.
Appendix 1
Excerpt of Board of Health Minutes from Tuesday, October 13, 1998
Meeting No. 12
132. Cyclospora Outbreak in Spring 1998
The Board of Health had before it a report (October 1, 1998) from the Medical Officer of
Health recommending that:
(1)The Ontario Minister of Health make cyclosporiasis a reportable disease in Ontario;
(2)The Federal Minister of Health make cyclosporiasis a reportable disease in Canada and
put in place mechanisms for active surveillance of important foodborne diseases such as
cyclosporiasis;
(3)The Ontario Minister of Health recommend that laboratories in Ontario routinely test for
cyclospora oocysts in stool specimens submitted for ova and parasites;
(4)Toronto Public Health continue to increase awareness and knowledge about foodborne
illnesses by providing relevant and timely information to health care providers and the public;
(5)Health Canada, in conjunction with Agriculture and AgriFood Canada (AAFC) and the
Canadian Food Inspection Agency (CFIA), conduct further basic and applied research on the
biology and epidemiology of cyclospora, e.g. mechanisms by which contamination occurs,
effectiveness of control measures during high produce production periods;
(6)Health Canada and the CFIA develop a coordinated approach to the development of
policies regarding importation of fresh produce which includes:
(a)a more vigilant and rigorous approach, erring on the side of public health and safety;
(b)comprehensive risk assessment, including review of relevant international
epidemiological data and studies conducted by other health agencies; and
(c)work in partnership with the U.S. as appropriate;
(7)Toronto Public Health continue to actively participate in discussions re the spring 1999
policy for Guatemalan raspberry importation, and take the position that there should be a
restriction on these imports until:
(a)further information is available from Guatemala on the farm tracebacks from the 1996,
1997 and 1998 outbreaks;
(b)more is known about the mechanism of contamination with cyclospora; and
(c)there is independent audit evidence of compliance by individual farm with the Model
Plan of Excellence (MPE);
(8)The Board of Health express support for and interest in participation in the development
of a coordinated and coherent foodborne outbreak investigation protocol at the federal level by
Health Canada, AAFC and the CFIA, in consultation with health and agricultural authorities
at the provincial and municipal levels;
(9)CFIA ensure that their inspectors receive training in doing comprehensive food traceback
investigations as per the Centers for Disease Control & Prevention (CDC) protocol;
(10)The Ontario Minister of Health provide increased funding for the Public Health Branch
to provide strong support and coordination in multi-regional and province-wide outbreaks;
(11)The Ontario Minister of Health provide continued funding for the Central Public Health
Laboratory to enhance research and investigative abilities re foodborne pathogens and provide
opportunities to liaise with international counterparts;
(12)The Ontario Minister of Agriculture, Food and Rural Affairs invite a municipal public
health representative to join the newly-formed Steering Committee to develop a Food Safety
Strategy for Ontario;
(13)Health Canada and the CFIA amend federal health protection legislation with respect to
potential foodborne illnesses to permit them to take health protective actions based on
"reasonable and probable grounds" and afford protection from personal liability for any act
"done in good faith" (i.e. similar to the Ontario Health Protection & Promotion Act);
(14)Health Canada, in consultation with the CFIA, conduct an investigation to establish the
mode of cyclospora contamination in raspberries;
(15)The CFIA examine the feasibility of requiring the implementation of preventive and
control measures such as those contained in the MPE to all imported and domestically grown
produce (based on the fact that such measures are not specific to raspberries or cyclospora and
would contribute to the overall minimization of the risk of contamination of other food-borne
pathogens);
(16)The CFIA consult with stakeholders including the general public, and health and
environment agencies at the local, provincial and federal level to develop the position paper
on the development of a Code of Practice for the production, harvesting and packaging of
fresh fruits and vegetables for the CODEX Alimentarius Commission;
(17)The Medical Officer of Health review the health and environmental impacts of available
food treatment technologies and assess their effectiveness in eliminating foodborne pathogens;
(18)The federal Minister of Agriculture and Agrifood and the provincial Minister of
Agriculture, Food and Rural Affairs amend the Canadian Agricultural Products Act, the
Consumer Packaging and Labelling Act, and the Ontario Farm Products Grade and Sales Act
regarding country of origin labelling for all fresh and cooked fruits and vegetables sold at
wholesale, retail or in clerk-served operations to ensure consumers can always acquire
information about the origins of the food they are consuming. In making these amendments,
the federal and provincial ministers should ensure that their respective amendments cover all
possible purchasing scenarios;
(19)The federal Minister of Agriculture and Agrifood and the provincial Minister of
Agriculture, Food and Rural Affairs increase the number of staff available to do enforcement
work, particularly concerning country-of-origin labelling at retail to the public.
The Board of Health also had before it a Press Release from the Embassy of Guatemala
Dr. Yaffe gave a presentation to the Board on this report.
On motion by Councillor Filion, the Board of Health adopted the report (October 1, 1998)
from the Medical Officer of Health subject to the addition of the following recommendation:
"(20)The Canadian Food Inspection Agency be requested not to allow Guatemalan
raspberries to be brought into Canada until they have been shown to be contamination-free."
(Ontario Minister of Health, Federal Minister of Health, Agriculture and AgriFood Canada,
Canadian Food Inspection Agency, Ontario Minister of Agriculture, Food and Rural Affairs -
(signed by Chair))
