February, 1997
Southwest Regional Food Safety Committee Members - 1997
| Corrinna Brudner, Chairperson | Windsor-Essex County Health Unit |
| James Reason | Grey Bruce Health Unit |
| Heather Cottom | Elgin-St. Thomas Health Unit |
| Martha Giesbrecht | Elgin-St. Thomas Health Unit |
| John Orr | Huron County Health Unit |
| Eric Serwotka | Kent-Chatham Health Unit |
| Ewilla Castellan | Lambton Health Unit |
| Jo-Ann Powell | Middlesex-London Health Unit |
| Toni Moran | Middlesex-London Health Unit |
| Francine Paquette | Oxford County Health Unit |
| Amy Chui | Perth County Health Unit |
| Observing Member: Carolyn Biglow | Waterloo Regional Health Unit |
ASPHIO - Southwest Region
| Clayton Wardell, Chairperson | Grey Bruce Health Unit |
For further information, contact:
| Corrinna Brudner or tel. (519) 258-2146 ext. 243 Windsor-Essex County Health Unit, 1005 Ouellette Avenue, Windsor, OntarioN9A 4J8 |
Clayton Wardell tel. (519) 376-9420 ext.223 Grey Bruce Health Unit, 920-1st Avenue West, Owen Sound, Ontario N4K 4K5 |
A Review of Ontario’s Food Safety Program Administered by Health Units
TABLE OF CONTENTS
2.1 Foodborne Health Risks
3.0 THE FOOD SAFETY PROGRAM IN ONTARIO
3.1 Effectiveness of the Program
The need for a review of the food safety program in Ontario’s Health Units is obvious when one considers the recently announced realignment of health programs, the drive by government for greater effectiveness and efficiency, and the limited and shrinking resources available to carry out programs. As health professionals, Public Health Inspectors have a unique role and responsibility in delivering food safety programs in Ontario and throughout Canada. The South West Regional Food Safety Committee (SWRFSC) in cooperation with the Association of Supervisors of Public Health Inspectors of Ontario, (ASPHIO) Southwest Region, has undertaken a review of Ontario’s food safety program being delivered at the municipal level.
We offer our review of "Food Safety" as a key component for future decision making.
Ontario’s food safety program is delivered at the municipal level by 41 Health Units. These local agencies plan and deliver food safety initiatives under the guidance of the Mandatory Health Programs and Service Guidelines, issued by the Ministry of Health in 1989. The goals and objectives set in the guidelines have provided focus and direction for province wide activities in district Health Units. Today, Ontario is in the enviable position of having a food safety program that is being copied worldwide. Although the program is considered successful outside of Ontario, this success has only been achieved by continual change and improvement to the system. This review, in keeping with the philosophy of continual change and improvement, has identified several areas that warrant attention.
The safety of Canada’s food supply is the envy of the world. It is often taken for granted that less than a hundred years ago, molds and rancidity were a serious threat to health. In many countries that still is the case. Modern food controls are responsible for saving millions of lives. They have eradicated a vast number of diseases caused by food poisoning.1
Worldwide, food is the major source of exposure to pathogenic agents, both chemical and biological, from which no one in either developing or developed countries is spared. Foods contaminated with unacceptable levels of pathogens and chemical contaminants or having other hazardous characteristics, impose substantial health risks to consumers and severe economic burdens on individual countries and nations.2
Food safety experts in Canada, United States and other developed countries rank foodborne contaminants as the greatest risk to the food supply.2,3,4 The acute illness posed by foodborne organisms coupled with the ease and swiftness with which they develop, present food safety challenges for the entire food distribution chain including producers, packers and shippers, processors and manufacturers, retailers and consumers.4
Reports from Health Canada estimate that over two million cases of foodborne disease occur in Canada each year generating up to one billion dollars annually in direct medical expenses, lost income, legal expenses and other costs.5 Foodborne illnesses from six bacterial pathogens, all found in animal products, - Salmonella, Campylobacter jejuni, Escherichia coli 0157:H7 (commonly called hamburger disease), Listeria monocytogenes, Staphylococcus aureus and Clostridium perfringes - are estimated to account for 2.9 - 6.7 billion dollars in human illness costs each year.6 Supporting Canadian figures, microbial pathogens in food in the United States cause an estimated 6.5 million to 33 million cases of human illnesses and up to 9,000 deaths annually.
To date, more than 250 foodborne diseases have been identified.7 While many microorganisms may cause foodborne illness, some of the well-recognized microorganisms are considered re-emerging because they have recently become more common in food or have been found in new and different food. E. coli 0157:H7 is one of these emerging pathogens. E. coli 0157:H7 was first identified as a source of trouble in 1982 and is now turning up in undercooked hamburgers, pork, lamb, chicken, turkey and has even been found in potatoes. Researchers were doubly surprised when E. coli was the cause of tainted apple cider and mayonnaise because it normally can not survive in these acidic environments.8 These new foodborne disease threats are occurring because of increased international travel and trade, microbial adaptation, changes in the food production system and changes in human demographics and behaviour.9
In addition to the emergence and re-emergence of pathogens, the population of highly susceptible people is expanding and the threat of foodborne pathogens is great. Susceptible populations are expanding due to aging, underlying medical conditions, HIV and malnutrition. People with weakened immune systems become infected with foodborne diseases at lower doses that may not produce an adverse reaction in healthier persons. Particularly for the elderly, foodborne infections are likely to invade their blood stream and lead to severe illnesses with high mortality rates.9 Other susceptible groups include pregnant women, their unborn fetuses and infants. Complications may lead to spontaneous abortions, still births, meningitis and kidney failure in infants.4
Estimates vary widely of the prevalence and growth of foodborne illness. One reason for the varying estimates is that many people afflicted with foodborne illness assume they have the "flu" and do not visit a physician, cases therefore tend to be under reported.4 Another influence is that in order to be included in national statistics, a person must be infected, become ill, consult a doctor, and be sent for tests. A lab test must identify the illness-causing bacterium, recognize it as foodborne, and report it to the local health department, which in turn must report it to the Laboratory Centre for Disease Control in Ottawa. Any break in the chain will leave the case among the estimated rather than the confirmed statistics.10 For every case of foodborne illness, it is estimated that 25 go unreported.9
The Ontario Ministry of Health has indicated that one in eight Ontarians will have
suffered from food poisoning,5 with most
reported cases traced to restaurants and institutions. In addition to the under reporting
of foodborne illness, the Centre for Disease Control also notes that reports of outbreaks
represent "only a small fraction of the total numbers that occur".7
Canada’s food industry is changing and growing rapidly along with concerns for food safety and security. Canada’s food industry is a major sector of the economy employing 670,000 in food service.11 Canadians now spend an average 10% of their disposable income on food.12
Canadians import about one fifth of their food supply.11 These imported foods are an increasing proportion of the diet, and often come from developing countries where food hygiene and basic sanitation is less advanced. Food processing technologies are constantly evolving. The centralization of the food industry means that a single contaminated product may appear in different foods and in many different forms, and infect a considerable number of people before it is identified.13
The movement in recent years towards free trade agreements and reduced trade barriers has provided tremendous potentials for food importers and exporters alike. As tariffs are removed, competition within the international food industry has become fierce. In an effort to ensure that the Canadian food industry remains competitive, an increasing amount of pressure has been levied against the Federal government to redesign and "harmonize" current inspection systems so as to be more consistent with international standards.12
What impact will all these changes in the food industry have on the future of food safety in Canada and more specifically, Ontario? The long-term effects have yet to be determined but analysts are already seeing problems resulting from the fact that almost everything about the way we produce, distribute and consume our food has changed over the course of the past several decades. New techniques in agriculture have in some cases made animals more vulnerable to infection, and large-scale food production has also meant that when tainted food gets out into the marketplace, it goes far beyond the local grocery store.14
Our choice of food products has been expanding rapidly since the mid 1970’s. The number of products available in Ontario supermarkets by 1990 has skyrocketed to 30,000 compared to 9,000 in 1975.15 The influx of new food products brings with it an increased risk, to food safety and of new and potentially dangerous foodborne pathogens.
The food retail and hospitality industry are growing.16 Dramatic changes in the lifestyles of the Canadian public have led to greater numbers of people eating meals prepared in establishments ranging all the way from fine dining through fast food outlets to street vendors. In addition, catering services, meals on wheels programs and community kitchens have also become increasing popular in conjunction with changing population demographics.
Unfortunately, this boom in food service establishments has not been matched by a similar growth in food safety education and control.
The food industry, noted for its high staff turn-over rates and lack of formal training programs, is further characterized by workers that have limited knowledge about the importance of sanitation and personal hygiene in respect to food handling.17 Without the ongoing food safety training seminars provided by Public Health Inspectors, knowledge regarding the primary factors associated with foodborne outbreaks would not reach foodhandlers unless those individuals are actively seeking to educate themselves.18
It is vital that foodservice workers continue to receive the training required to allow
them to perform their duties in a manner that will not contribute to the contamination of
foods they prepare. It is also necessary that food safety information be delivered in a
consistent and accurate manner.
Foodborne disease is obtaining increasing attention in the eye of the public. There is much publicity concerning Salmonellosis, Listeriosis and "hamburger disease" (Enteritis caused by E coli 0157:H7). Food previously thought to be relatively safe when stored such as ice cream, soft cheese and shell eggs, are being discovered to contain pathogens which are multiplying under storage conditions.19
Due to current lifestyle changes, consumers are eating more commercially prepared food and have less time to spend preparing meals. Outbreak investigations indicate consumers do not always take precautions to reduce risks of foodborne infections.20 Because of the diverse nature of these outbreaks, public education is one key to their prevention. The following results highlight a Consumer’s Association of Canada survey measuring the attitudes and opinions regarding the safety of the Canadian food supply.
Evidence suggests that there needs to be a link between food safety professionals and the consumer. Consumers’ perceptions of the riskiness of an activity or product are frequently quite different from the actual hazard involved. The issue of food safety is also related to the degree of trust and confidence consumers have in the food industry and the government regulatory process.22
The consumer is also playing an increased role in food handling where large groups may be served. This includes a surge in food related charity events as food has become a big part of both fund raising and entertainment. During the period 1982 - 1989, the highest case per outbreak ratios were associated with catered events, which reached 102 cases per outbreak.9 The risk of food poisoning is often increased in these settings due to off-site food preparation several hours before consumption, and subsequent reheating of the product for service at less than 60ºC.9
The problem lies with the consumer who must try to find credible sources of food safety
information. Most of the information the consumer receives comes from the news media. The
news media while providing a good venue for distributing information often falls short in
providing the necessary content for understanding a problem and thereby effecting change
in behaviour. Findings of a qualitative study titled "Food for Thought",
recently compiled for the International Food Information Council Foundation, showed that
the media seldom provided the context to understand food safety.23 The Public Health Inspector, on the other hand, has
formal training in food safety and sanitation and keeps updated on current food safety
literature. Given this situation, government initiatives are needed to educate the
consumer.
We are fortunate to live in an age, where scientific breakthroughs have afforded us the means to deal with many of the diseases and pathogens, which in the past cost millions of lives. In addition, we are being forced to become increasingly aware of the fact that advancing technologies, combined with changes in the way we live, eat and interact with others, have in many ways made us more vulnerable to infectious diseases.24
Of particular interest are the present control measures and monitoring techniques utilized to gain control over many pathogens transmitted through food and water. Canada’s food inspection system is respected world wide for producing safe, high quality food. Apparently, this alone is not enough to consider it successful.25 In this time of economic constraints, we are being looked at to become more accountable for every dollar spent. The ever shrinking resources have stimulated questions regarding the effectiveness of the current food inspection system.
Currently, there are questions as to whether statistical evidence exists which supports that present interventions are reducing the incidence of foodborne illness. Although there is well-documented evidence that supports that there is considerable variation in restaurant inspections as well as education of food handlers throughout Canada,26 the variation does not signify that the current food safety efforts are not making a difference.
What does exist, however, is evidence that removal of routine inspections at the retail food service level has resulted in serious outbreaks of gastrointestinal illness. One such case was documented by the Centre for Disease Control after they stopped routine bi-annual inspections of cruise ships.26 Removal of these barriers may result in unprecedented re-emergence of pathogens once thought to be a minimal threat to humankind.
Decisions to alter current food safety practices should be supported by improved
surveillance and study to ensure that the changes are resulting in the reduction of
illness. Innovative ideas should be explored to augment existing databases and to increase
foodborne disease reporting27 as well as being
able to provide additional data that can be used to evaluate and improve new interventions
prior to implementation.
When assessing the food program at the local Health Unit level, it is important to look at whether the program is in line with the health goals set by the Premier’s Council on Health Strategy for the people of Ontario. The Food Safety Program is compatible with three of the five goals:
Not surprising, Health Units’ mandates already focus on these goals. As well, interventions suitable for reduction of risk factors associated with disease are in place.
In Ontario, the legal authority for controlling foodborne disease is the responsibility
of local Health Units. The Health Protection and Promotion Act,29 section 5, identifies the Board of Health as the
provider of mandatory programs that include community sanitation for the prevention or
elimination of health hazards and the control of communicable disease. As well, section 10
(2) states that the Medical Officer of Health must inspect or cause the inspection of a
food premise and any food and equipment therein, within the Health Unit jurisdiction.
Further, under section 40 of the above mentioned Act, the Public Health Inspector has the
right of entry and examination of any food premise.
Health Units are responsible for administering the food safety program at the retail food service level. As a result of this mandate, the Public Health Inspector has established a valued presence in the community, both in the eyes of the general public and those employed in the food industry.
The role of a Public Health Inspector in the community is multi-faceted. The ability to carry out such multiple tasks speaks volumes of the skills of these individuals. Merely reviewing the compulsory scholastic requirements that comprise the basis for certification of a Public Health Inspector would therefore not do justice to, nor clearly reflect the ability that they possess.
The educational background and experience of the Public Health Inspector provides a solid foundation in the principles of food biology, food hygiene, parasitology and infection control. This scientific knowledge in conjunction with that of the pertinent legislative requirements and legal training has afforded the Public Health Inspector the flexibility to be both educator and enforcer.
The hands-on experience of the Public Health Inspector has allowed them to acquire an "operator-relevant" perspective of food safety. Daily interaction with food handlers, familiarity with the current food safety issues along with continual training in adult education allows the Public Health Inspector to effectively and efficiently educate and work with individuals in the food service industry.
The capability of Public Health Inspectors to combine interpretation skills with the
ability to effectively perform food safety risk analysis has resulted in Health Units
addressing food safety issues in a prompt and effective manner.
The system of mandatory controls draws its strength from one simple principle: the best way to provide safe, high quality food is to build safety in during processing.30 The Hazard Analysis Critical Control Point (HACCP) system, identified in the Mandatory Food Safety Protocol,31 has been recognized as an enhanced systematic approach to inspecting and evaluating food systems.32 The concept of HACCP is beneficial because the critical areas in an operation are looked at and assessed based on their potential risk for causing foodborne illness.
HACCP focuses primarily on food preparation processes instead of design criteria and basic sanitation levels. Epidemiological data indicates that ensuring safe food preparation is a key strategy in preventing foodborne illness. According to CDC Surveillance Summaries from 1973 through 1987, mishandling of food in food service establishments accounted for 44.6% of the total outbreaks reported. Improper holding temperature was associated with most of the outbreaks for all the reporting years. The remaining factors were poor personal hygiene, inadequate cooling, contaminated equipment and obtaining food from unsafe sources.17 These contributing factors are consistent in Ontario as described in the Food Safety Protocol.
The development of HACCP systems is often more complex in retail food operations than it is for food processing plants. The retail food operation must involve coverage of all the potentially hazardous food which frequently totals between 50 and 500 foods. Therefore, success of the HACCP system in a retail food operation in ultimately ensuring safe food is prepared in an establishment depends on management’s commitment of time and financial resources.27
The HACCP approach has been adopted by Canada and the United States at many different legislative levels. Internationally, it is being incorporated into Codex documents and being taught in training courses by the World Health Organization.33 As well, some progressive corporate retail food operations (generally those with large operational budgets) have begun to integrate the HACCP system into their establishments. Most small corporate or individually operated establishments have not yet implemented HACCP. Presently there is no responsibility on the part of the industry to adopt and accept these principles. Barring that the principles of this system rely heavily on the involvement by the establishment’s personnel (management and food handlers), it is doubtful it can work effectively at reducing foodborne illness without some form of mandated responsibility for the entire retail food industry. Establishments need to develop a HACCP plan tailored to their own premise, implement and maintain it, and document data on an on going basis. How this could and should be accomplished while beyond the scope of this paper is well within the capacity of local Health Unit staff.
Based on the current Mandatory Food Safety Protocol, a multiple strategy approach, utilizing the HACCP principles to prevent foodborne illness already exists in Health Units. By means of risk based assessments of food premises, the Food Safety Protocol outlines an action response strategy framework that allows for educational and regulatory enforcement responses aimed at diminishing those contributing factors associated with foodborne illness. This strategy includes compliance inspections, HACCP audits, enforcement activities, foodborne illness investigations, and health promotion and education.
Health Units presently conduct HACCP audits in those food premises assigned a high or medium risk. During an audit, the Public Health Inspector follows the flow of a menu item (a specific food item such as chicken) through the establishment, identifies critical control points, ensures proper control measures are in place at these points and takes appropriate corrective action when necessary. The HACCP method recently introduced in Ontario is now being copied throughout Canada, United States and other parts of the world. We are fortunate in Ontario in that the people who deliver food safety strategies at the local level, namely Public Health Inspectors, identified the need for change and supported this new health strategy.
Public Health Inspectors are currently critically evaluating the system to make improvements in its effectiveness and efficiency. In particular the Canadian Institute of Public Health Inspectors (CIPHI) and ASPHIO have been key players to recommend and implement changes. For example the South West Regional Food Safety Committee (SWRFSC) is but one group of Public Health Inspectors (writers of this report) who have contributed to this change by developing a modified HACCP system. The intent of the modified system is to enable the Public Health Inspector to make better use of his or her limited time in a food premise. Through this and other means Ontario has the ability to have one of the most effective and cost efficient food safety programs in the world. The HACCP system continues to be modified and improved by professional organizations representing Public Health Inspectors in Ontario with support from the Public Health Branch, Ministry of Health. This community based approach appears to work well in most aspects of government. If we hope to continue developing an effective food safety program in Ontario it is important for both provincial and local governments to continue to support professional efforts to improve and streamline the system.
Compliance inspections are conducted on all food premises to ensure compliance and enforcement of food premise regulations. Problems arise when one recognizes that current regulatory controls contain only 29% content on food and food handling while the bulk of the regulatory criteria deals with structure and facilities.34 The legislation is therefore not consistent with the epidemiological approach. The HACCP system, if properly implemented and continuously practiced, offers a valuable means of institutionalizing safe food practices. Food safety legislation without this basis inevitably will needlessly increase the cost of food and may prove detrimental to the cause of public health.27
Therefore, the role of the HACCP process, within the scope of Health Units, should be
to verify HACCP systems exist in retail food establishments, to evaluate the system by
concurrence of identified critical control points and control measures, and to enforce
non-compliance with the HACCP system and regulatory controls.
The local Health Unit has a key role in investigating and responding to food complaints
where illness has resulted, where an infraction by a food premise is alleged, and in cases
of food recalls and illness outbreaks related to food in the community. In some
complaints, speed is of the essence. The Public Health Inspector can commence
investigations on site within one or two hours.35
Health Units keep up to date lists of all food premises and operators in their geographic
area, and staff make routine visits to these premises. Public Health Inspectors have an
established rapport with the operators of food premises and are therefore able to deal
quickly and efficiently with complaints. As well, these professionals are skilled at
collection and analysis of data associated with these types of investigations.
The responsibility of providing safe food to the public lies in the hands of the food handler and must be taken seriously.36 The job of a food handler may not sound as important as a medical doctor but the consequences of mishandled food can mean life or death in some instances.36 As stated in a letter to the Ontario Branch News, in order for people to be able to comply with safe food handling practices, they must first be aware of them. Education interventions are one strategy to increase awareness.37
It has been demonstrated that knowledge about proper food handling techniques is a powerful tool when learned and applied. These techniques can assist the operator to manage their food service ventures prosperously and safely.38 For effective results, they also need an explanation why they should change old habits.39
The Food Safety Protocol issued by the Ministry of Health for Ontario recommends that having a food handler knowledgeable in food safety procedures is an integral part of the HACCP system.33 Food safety training programs offered by Health Units are based on an establishment’s potential to cause foodborne illness. Priority is given to employees and operators of high and medium risk food premises. Although food safety is a component of the Ministry’s Protocol, it is currently very difficult to get many establishments to participate. Some operators take the position that if it was important, it would be legislated. Large corporate and franchised establishments and institutions generally already have some formal training in place or are more receptive to education offered to them. However, in smaller independent establishments, food safety training is generally low or lacking and these establishments express little interest to offers made by Health Unit staff.
While few evaluation studies have been conducted to demonstrate the direct effect that food handler education has on the reduction of foodborne illness, at least one study has shown that previous training had an impact on the food handler’s test scores with respect to proper food handling techniques.40 Food handlers who had previous training scored on average 25% higher than those with no previous training. The impact of training is even more prominent if the restaurant managers are certified. It was found that restaurant managers who became certified in the mandatory programs reported that their premises were three times as likely to fare better in inspections by regulatory bodies.41 One can infer that if inspection scores have improved then food handling practices have also improved and the potential to cause foodborne illness has decreased. More research needs to be conducted to more fully evaluate the effectiveness of food handler training.
While mandatory food handler training is supported by most Health Units and the
Canadian Institute of Public Health Inspectors (CIPHI), it has yet to be legislated.
Consumer education is also an important part of any food safety program but one that is often overlooked or inadequately handled by government initiatives. It is estimated that 23% of all reported food poisoning investigations results are traced to meals prepared in their own homes.42 Because Health Units are locally based and therefore visible and accessible to the consumer, they make an appropriate choice to facilitate and coordinate this component of the program. The skills of the Public Health Inspector enables them to analyze and plan strategies based on consumer need and knowledge level.
With limited resources, Health Units should use a multiple strategy approach incorporating the resources of other organizations such as the provincial government, Canadian Institute of Public Health Inspectors, the food service industry, media and other locally based agencies. The following are a few examples:
Educated consumers are better equipped to make informed decisions about the safety of the food when dining out and the safety of food prepared in their own home. As a result, it may stimulate better food handling practices by food establishments as they compete for the consumer’s business. This is one area that needs more emphasis and support at the local level.
There have been dramatic changes in Canadian lifestyles over the past few decades. Current estimates tell us Canadians are spending 25 billion dollars annually for food and beverages outside the home. The boom in food retail and service establishments however has not been matched by a similar growth in food safety control. Each year in Canada up to one billion dollars is spent on medical support, lost income and associated expenses related to over two million cases of illness originating from food. Considering these costs food safety is worthy of everyone’s attention.
Safe food does not happen by accident. Currently the government, the food industry and the consumer all play a role. We have been fortunate in Canada and particularly Ontario that governments have recognized the advantages of preventative food safety programs. The security of Canada’s food supply is the envy of the world and Ontario is currently viewed as an innovator and leader in food safety. Throughout Canada, Public Health Inspectors provide comprehensive and effective food safety services directly to the consumer at the local level.
Public Health Inspectors working in partnership with the Ontario Ministry of Health introduced the HACCP (Hazard Analysis and Critical Control Point) process to complement traditional "inspections" and bring greater effectiveness and efficiency in food safety operations. This new approach is now viewed as the best available model for a food safety system and is being copied throughout North America and the world.
The infrastructure currently in place in Ontario evolved over many years through the
assistance of Public Health Inspectors and their professional bodies. Support by local
government and the Province of Ontario is an essential element. This approach has worked
well to date as evidenced by our current strength in food safety in Ontario. The need for
continued research and evaluation in applying food safety strategies must continue if we
are to maintain our control over foodborne illness.