FoodNet Canada annual report 2016

Table of contents

• Foreword
• Acknowledgements
• Information to the reader
• Campylobacter
  • Human surveillance summary
  • Food, animal and environmental surveillance summary
  • Public health impact
• Salmonella
  • Human surveillance summary
  • Food, animal and environmental surveillance summary
  • Salmonella Enteritidis
  • Other Salmonella serovars of interest
    • Salmonella Kentucky
    • Salmonella Typhimurium (S. I 4,[5],12:i:1,2) and Salmonella I 4,[5],12:i:-
    • Salmonella Heidelberg and Salmonella Infantis
  • Public health impact
• Shigatoxigenic escherichia coli (STEC)
  • Human surveillance summary
  • Food, animal and environmental surveillance summary
  • Public health impact
• Listeria monocytogenes
  • Public health impact
• Yersiniosis
  • Public health impact
• Shigellosis
  • Public health impact
• Parasites and viruses
  • Giardia
  • Cryptosporidium
  • Cyclospora
• Retail sampling summary
• Public health impact
• Appendix A — non-human sample types tested in 2016
• Appendix B — abbreviations and references

Foreward

The Public Health Agency of Canada's FoodNet Canada surveillance system is pleased to present the new annual report. In the past, FoodNet Canada produced both a 'short' and 'long' report to disseminate surveillance results on an annual basis. Based on feedback obtained through stakeholder consultation, these two reports have been replaced with one streamlined annual report. The current report outlines the results of our surveillance activities conducted in 2016.

The report highlights FoodNet Canada findings from its sentinel sites in British Columbia, Alberta and Ontario. It focuses on trends in enteric pathogen disease rates, as well as trends in the prevalence of these pathogens found on potential disease sources: retail meats, food-animal manure and water. We also highlight the impact of enteric pathogen trends on public health. In 2016, FoodNet Canada added feedlot beef manure sampling in the Alberta site and turkey manure sampling in the Ontario site, which further informs our 'farm to fork' surveillance approach.

It is our hope that this report will be used to inform and shape discussions on food safety issues regarding enteric diseases and their sources.

Acknowledgements

FoodNet Canada acknowledges the significant investments made by our partners in the three sentinel sites, our provincial and federal government agency colleagues, and academic and industry collaborators who help to make this program a continued success.

Information to the reader

FoodNet Canada is a multi-partner sentinel site surveillance system led by the Public Health Agency of Canada (PHAC) that monitors changes in enteric pathogens in Canada.

In collaboration with public health jurisdictions and provincial laboratories, FoodNet Canada conducts continuous and episodic surveillance activities in three sentinel sites collecting information across four components: human, retail (meat and produce), on-farm (farm animals), and water. Continuous surveillance occurs throughout the year to identify trends in human disease occurrence, exposure sources, and attributes illnesses to sources and settings for targeted enteric pathogens. Information on the sources of greatest risk to human health helps direct food and water safety actions and programming as well as public health interventions, and to evaluate their effectiveness. Specifically, FoodNet Canada's core objectives are to:

• determine what food and other sources are making Canadians ill;
• determine significant risk factors for enteric illness;
• accurately track enteric disease rates and risks over time; and
• provide practical prevention information to assist local and provincial public health officials to:
  • prioritize risks;
  • compare interventions, direct actions and advance policy; and
  • assess effectiveness of food safety activities / public health interventions and measure performance.

This report draws on knowledge from a variety of sources to present a comprehensive and meaningful interpretation of trends and issues identified through FoodNet Canada data, as well as from collaborating programs within PHAC. Examples include the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS), the National Enteric Surveillance Program (NESP), the Enhanced National Listeriosis Surveillance Program, the Outbreak Management Division (OMD), and the National Microbiology Laboratory (NML). Information from these programs is used to support and enhance findings through the integration and assessment of relationships observed over time between human illness, contamination levels in retail foods, food-animal farm manure and water. Known interventions implemented within the food industry were also considered when interpreting surveillance trends.

Data collection and reporting

Each FoodNet Canada sentinel site relies on a unique partnership with the local public health authority, private laboratories, water and agri-food sectors as well as the provincial and federal institutions responsible for public health, food safety, and water safety. The sites include Ontario (Middlesex-London Health Unit), British Columbia (Fraser Health Authority) and Alberta (Calgary and Central Zones of Alberta Health Services). The Ontario (ON) site data collection began in August of 2014; however, for the purpose of yearly comparisons in this Report, data from the ON pilot sentinel site (Region of Waterloo) (2011-Mar 2014) have been included for select analyses. The British Columbia (BC) site was officially established in April 2010 and includes the communities of Burnaby, Abbotsford, and Chilliwack. The province of Alberta (AB) contains the third site and data collection began in June of 2014.

Results are reported for all three sites unless otherwise stated. Readers should be cautious when extrapolating these results to areas beyond the sentinel communities. As additional sentinel sites are established, comprehensive information from laboratory and epidemiological analyses from all sites will provide more representative national trends in enteric disease incidence and exposure sources to inform accurate estimates for all of Canada.

In 2016, the farm and retail components were implemented across all sites in ON, AB, and BC whereas the water component was only implemented in AB and BC. The non-human surveillance data collected by FoodNet Canada represents possible exposure sources for human enteric illnesses within each sentinel site. The data are meant to be interpreted aggregately and cannot to be used to directly attribute a specific human case reported to FoodNet Canada to a positive isolate obtained from an exposure source. In this report, the non-human and human data are integrated using descriptive methods. The term "significant" is reserved in this report for describing trends that are statistically significant.

FoodNet Canada retail and farm sampling is integrated with CIPARS. This has included the streamlining and sharing of sampling and sampling sites, retrospective and prospective testing of antimicrobial resistance in selected bacteria isolated from FoodNet Canada samples, and improving data management mechanisms to maximize data linkages. CIPARS monitors trends and the relationship between antimicrobial use and antimicrobial resistance in selected bacterial organisms from human, animal, and food sources across Canada to inform evidence-based policy decision making to contain the emergence and spread of resistant bacteria. For further information about CIPARS, please refer to the program's website.

Surveillance strategy

Human surveillance

Public health professionals in each site use FoodNet Canada's enhanced standardized questionnaire to interview reported enteric disease cases (or proxy respondents). Information on potential exposures collected from the questionnaires is used to determine case status (e.g. international travel versus endemic) and compare exposures between cases. In addition, advanced subtyping analyses on isolates from case specimens are conducted for further integration with non-human source information.

Retail surveillance

The retail stage of food production represents the point closest to consumers through which they can be exposed to enteric pathogens through contaminated food. Both retail meat and produce samples are collected on a weekly basis from randomly selected grocery stores within each site. FoodNet Canada collects samples of raw unfrozen skinless chicken breasts and ground beef on a weekly basis. Each year, FoodNet Canada and its partners assess knowledge gaps and from this process, select targeted retail products to sample for a given year (see Appendix A for 2016 details). In past years targeted meats have included but were not limited to pork chops, ground chicken and turkey, and uncooked frozen breaded chicken products, such as nuggets and strips. In 2016 FoodNet Canada opted to continue the targeted investigation of frozen breaded chicken products that began in 2011. Testing continued in 2016 as in previous years with Campylobacter and Salmonella being tested for among all chicken products, Listeria spp. for all retail meat products, and Shigatoxigenic Escherichia coli (STEC) for ground beef samples. In addition, vegetables and ready to eat slaws were tested for the presence of Listeria, Cyclospora, Cryptosporidium, Giardia, Norovirus, and Rotavirus.

On-farm surveillance

The presence of enteric pathogens on farms (in animal manure) is a potential source of environmental exposure of enteric pathogens, and also represents an important source in the farm-to-fork transmission chain. In 2016, the farm component was active across all three sites, although commodities varied by site (Appendix A). Manure samples were collected from beef cattle, swine, broiler chicken, layer chicken, and turkey farms in order to estimate the pathogen levels on farms. Approximately 30 farms of each type of participating farm commodities were visited each year in each site. A short management survey, and up to six manure samples (usually fresh pooled samples) were obtained at each farm visit. All samples were tested for Campylobacter and Salmonella with the beef samples additionally being tested for E. coli O157 and STEC. Throughout the report, farm results are reported at both the sample-level and farm-level to account for clustering within farms. Sample-level results include all manure samples collected on each farm, while farm-level results are based on a threshold of one positive manure sample per farm to report a farm as positive.

Water surveillance

Water is another environmental source of enteric pathogens collected in the FoodNet Canada surveillance program.  In 2016 irrigation water was sampled in both the BC and AB sentinel sites and tested for Campylobacter, Salmonella, and STEC (Appendix A). Similar to 2015, sampling in BC was bi-weekly throughout the year and monthly in AB from June to September.

Definitions

Endemic case of disease

Affected individual who had an infection that was considered sporadic and domestically acquired (i.e. within Canada).

Exposure source

Point along the water-borne, food-borne, animal-to-person, or person-to-person transmission route at which people were suspected to have been exposed to a given pathogen.

International travel-related case of disease

Affected individual who travelled outside of Canada, and where the travel dates overlap with the expected disease incubation period (varies depending on the pathogen).

Lost to follow-up

Includes cases that could not be followed up with an interview by public health.

Non-endemic

Includes immigration-related cases where illness was acquired outside of Canada.

Outbreak-related case of disease

One of a number of affected individuals associated with an increased occurrence of the same infectious disease, whose illness is confirmed through a public health partner (ON, AB, and BC sites) on the basis of laboratory and/or epidemiological evidence.

Shigatoxigenic Escherichia coli (STEC)

Escherichia coli are normal intestinal inhabitants in humans and animals, and most strains do not cause enteric disease. However, the group of shigatoxigenic E. coli includes certain toxin-producing strains that can cause severe diarrhea and, in some people (particularly young children), a form of acute kidney failure called hemolytic uremic syndrome. In terms of nomenclature, shigatoxin (ST) -producing E. coli can also be referred to as Shiga-toxin-producing E. coli^Footnote 1.

Significant

The term "significant" in this report has been reserved for statistically significant findings (i.e. p < 0.05).

Campylobacter

Human surveillance summary

Table 1.1: Incidence rates (per 100,000 person-years) of Campylobacter spp. by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	10.07	15.98 ↑	15.85	17.90	21.90	21.38	15.90	18.28
International travel	5.24	4.57	5.25	4.48	6.38	9.34	5.52	5.67
Outbreak	0.42	0.00	0.00	0.00	0.00	0.00	0.10	0.00
Non-endemic	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Lost to follow-up	4.61	7.27	3.86	3.21	3.83	3.94	4.04	4.37
Total	20.34	27.82 ↑	24.97	25.59	32.10	34.66	25.56	28.32
↑/↓Indicates a significant increase/decrease in incidence compared to 2015.

Figure 1.1 - Text Description

Figure 1.1: Relative proportion of Campylobacter spp. by case classification.

Case classification	Number of cases	Relative proportion
Endemic	364	65%
Lost to follow-up	87	15%
Travel	113	20%

Figure 1.1 shows a pie chart of the relative proportion of Campylobacter cases in the FoodNet Canada surveillance system by case classification (endemic, lost to follow-up, non-endemic and travel) for 2016. The chart includes the case classification, the number of cases and the relative proportion.

Figure 1.2 - Text Description

Figure 1.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic Campylobacter spp. cases within FoodNet Canada sentinel sites, 2016.

Age category	Female	Male	Overall total (all genders combined)
0 to 4	29.28	36.06	32.75
5 to 9	14.15	9.86	11.93
10 to 14	1.88	17.71	10.04
15 to 19	9.02	27.17	18.37
20 to 24	15.23	35.39	25.68
25 to 29	17.56	28.14	22.87
30 to 39	19.17	19.69	19.43
40 to 59	14.91	18.24	15.66
60+	14.87	18.40	16.53
Overall total (all ages combined)	15.02	21.52	18.28

Figure 1.2 shows a bar chart of the annual incidence rate of Campylobacter per 100,000 population by overall total age category and by each age category and gender for 2016. The y-axis presents the incidence rate per 100,000 population and the x-axis presents the age categories. The bars represent the total incidence for all genders by age group as well as the total incidence of male and female separately by age category.

Food, animal and environmental surveillance summary

Table 1.2: Prevalence of Campylobacter spp. by sample type and FoodNet Canada sentinel site, 2016.

Sample type		Ontario site	Alberta site	British Columbia site	All sites
Chicken breast		37% (48/131)	38% (50/132)	45% (59/132)	40% (157/395)
Ground Pork		0% (0/132)	1% (1/132)	1% (1/132)	<1% (2/396)
Broiler chicken manure	Sample-level	5% (4/88) ↓	20% (24/120) ↓	24% (31/128)	18% (59/336)
	Farm-level	5% (1/22)	20% (6/30)	28% (9/32)	19% (16/84)
Turkey manure	Sample-level	56% (65/116)	NT	68% (79/116) ↓	62% (144/232)
	Farm-level	59% (17/29)	NT	72% (21/29)	66% (38/58)
Layer chicken manure	Sample-level	54% (28/52)	NT	NT	54% (28/52)
	Farm-level	62% (8/13)	NT	NT	62% (8/13)
Feedlot beef manure	Sample-level	NT	72% (56/78)	NT	72% (56/78)
	Farm-level	NT	100% (13/13)	NT	100% (13/13)
Irrigation water		NT	22% (7/32) ↑	20% (22/110)	18% (24/132)
↑/↓Indicates a significant increase/decrease in prevalence compared to 2015; NT-not tested.

Figure 1.3 - Text Description

Figure 1.3: Distribution of Campylobacter spp. subtypes among food, animal and environmental samples, FoodNet Canada, 2016

no data	Sample type
no data	Irrigation water	Feedlot beef manure	Ground pork	Layer chicken manure	Turkey manure	Broiler chicken manure	Chicken breast
Campylobacter jejuni	62.17	48.21	50.00	57.14	64.58	79.66	87.66
Campylobacter coli	20.69	48.21	50.00	42.86	36.64	4.08	16.13
Campylobacter lari	17.24	0.00	0.00	0.00	0.00	0.00	0.65
Other Campylobacter	0.00	3.57	0.00	0.00	0.00	2.76	0.00

Figure 1.3 shows a stacked horizontal bar chart that represents the distribution of Campylobacter jejuni, Campylobacter coli, Campylobacter lari and other Campylobacter positive samples by sample type (Feedlot beef manure,swine manure, turkey manure, broiler chicken manure and chicken breast) for 2016. The y-axis represents the sample type and the x-axis represents the percent of all Campylobacter positive samples. The stacked bars represent the percentage of Campylobacter for each subtype (Campylobacter jejuni, Campylobacter coli, Campylobacter lari and other Campylobacter) by sample type.

Public health impact

Seasonality in the incidence of Campylobacter cases and in the proportion of positive retail chicken products positive for this pathogen was observed in 2016, with higher rates and proportions reported in the month of July (Figure 1.4). While there was a marked decrease in the incidence of human campylobacteriosis at the end of the summer season, the proportion of retail chicken samples positive for Campylobacter remained stable and at higher levels compared to the winter and spring seasons.

Figure 1.4 - Text Description

Figure 1.4: Human incidence rate (per 100,000 person-years) for endemic Campylobacter cases and proportion of retail chicken samples positive for Campylobacter by month across FoodNet Canada's sentinel sites, 2016.

no data	All Sites	Ontario	British Columbia	Alberta
January	9.04	4.98	17.44	7.00
February	10.24	14.95	9.96	8.17
March	10.24	2.49	19.93	9.34
April	13.86	12.45	12.45	15.18
May	21.09	4.98	37.36	21.01
June	23.50	17.44	22.42	26.85
July	31.34	32.38	22.42	35.02
August	27.72	29.89	24.91	28.02
September	25.91	24.91	24.91	26.85
October	14.46	9.96	22.42	12.84
November	15.07	17.44	19.93	11.67
December	16.27	17.44	22.42	12.84

Proportion of retail chicken samples

no data	All Sites	Ontario	British Columbia	Alberta
January	47.22	67.00	42.00	33.00
February	20.00	13.00	20.00	27.00
March	25.00	17.00	44.00	11.00
April	30.56	25.00	42.00	25.00
May	26.67	13.00	47.00	20.00
June	39.63	11.00	33.00	44.00
July	63.64	64.00	67.00	60.00
August	38.89	42.00	4.00	33.00
September	61.90	67.00	67.00	50.00
October	52.94	53.00	43.00	60.00
November	58.06	42.00	70.00	67.00
December	no data	no data	no data	no data

Figure 1.4 shows two line graphs. The top line graph is the monthly incidence rate of Campylobacter per 100,000 (y-axis) by month (x-axis) for the total combined sentinel sites (Ontario, British Columbia and Alberta) and each of the individual sentinel sites Ontario, British Columbia and Alberta in 2016. The bottom line graph is the proportion of retail chicken breast samples that are positive (y-axis) by month (x-axis) for the total combined sentinel sites (Ontario, British Columbia and Alberta) and each of the individual sentinel sites Ontario, British Columbia and Alberta in 2017.

Data for retail samples collected in December have been excluded due to the low sample size (less than five) collected.

Campylobacter jejuni was the primary pathogen identified in both human cases and retail chicken samples across all sentinel sites. This subtype is also common in samples collected from irrigation canals, broiler chicken and turkey farms (Figure 1.3). Among human cases, Campylobacter coli are less frequently associated with disease, representing 5% of all subtyped human infections. However, within the animal sector, C. coli represented 20% and 35% of Campylobacter isolated from farm broiler chicken and turkey manure samples, respectively.

Food products have been identified as one of the most likely sources of infection in humans followed by animal contact. At the retail level, Campylobacter was frequently detected on chicken breasts (40%, 157/395) and less frequently on ground pork (2/396) in 2016. There are multiple sources of exposure at the farm level and Figure 1.5 presents the proportion of Campylobacter that was identified by farm type.

Figure 1.5 - Text Description

Figure 1.5: Proportion of manure samples positive for Campylobacter by farm type across FoodNet Canada's sentinel sites, 2016.

Farm type	Proportion of all positive manure samples
Broiler chicken	8%
Beef cattle	27%
Layer chicken	25%
Turkey	40%

Figure 1.5 shows a pie chart of the proportion of all positive Campylobacter manure samples by farm type (broiler chicken, swine, turkey and feedlot beef) in 2016.

Overall, when comparing the human and food trend information it is clear that there are other potential sources of exposure for human illness beyond chicken products purchased at the retail level. If chicken were to be the only source of exposure, we would expect to observe the trends of human illness to mirror those of retail chicken products and continue to be reported at higher levels after the summer season. Continuing surveillance of other retail products, farm animals and the environment for Campylobacter will allow us to better identify and understand the contribution of multiple sources to Canadian illnesses, as well as to guide future surveillance activities.

Salmonella

Human surveillance summary

Table 2.1: Incidence rates (per 100,000 person-years) of Salmonella spp. by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta siteTable 2.1 footnote a		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	10.49	12.66	16.05	14.69	17.43	17.85	15.03	14.96
International travel	5.45	4.98	6.34	5.35	6.59	7.68	6.18	5.83
Outbreak	0.84	6.44	2.48	1.17	0.85	4.77	1.69	3.31
Non-endemic	0.00	0.00	0.30	0.00	0.43	0.21	0.26	0.05
Lost to follow-up	0.00	0.42	2.48	1.56	3.19	1.25	2.04	1.21
Total	16.78	24.49 ↑	27.65	22.77	28.49	31.76	25.20	25.36
↑/↓Indicates a significant increase/decrease in incidence compared to 2015.

Figure 2.1 - Text Description

Figure 2.1: Relative proportion of Salmonella by case classification.

Case classification	Number of cases	Relative proportion
Endemic	298	59%
Lost to follow-up	24	5%
Non-endemic	1	0.2%
Travel	116	23%
Outbreak	66	13%

Figure 2.1 shows a pie chart of the relative proportion of Salmonella cases in the FoodNet Canada surveillance system by case classification of endemic, lost to follow-up, non-endemic, outbreak and travel for 2016. The pie chart includes the case classification and the relative proportion.

Figure 2.2 - Text Description

Figure 2.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic Salmonella spp. cases within FoodNet Canada sentinel sites, 2016.

Age category	Female	Male	Overall total (all genders combined)
0 to 4	34.45	40.98	37.80
5 to 9	21.23	11.51	16.19
10 to 14	9.41	10.62	10.04
15 to 19	12.63	13.59	13.12
20 to 24	22.85	19.82	21.28
25 to 29	16.21	12.06	14.12
30 to 39	13.22	18.82	12.52
40 to 59	12.78	11.81	11.47
60+	12.95	16.23	14.49
Overall total (all ages combined)	14.92	15.01	14.97

Figure 2.2 shows a bar chart of the annual incidence rate for Salmonella human infections per 100,000 population by age group and gender for 2016. The y-axis presents the annual incidence rate per 100,000 population, while the x-axis presents the different age categories and total for all age groups combined. The bars represent the total incidence for all genders, total incidence for male and total incidence for female cases.

Food, animal and environmental surveillance summary

Table 2.2: Prevalence of Salmonella spp. by sample type and FoodNet Canada sentinel site, 2016

Sample type		Ontario site	Alberta site	British Columbia site	All sites
Chicken breast		13% (17/131)	29% (38/132)	30% (39/132)	24% (94/395)
Frozen raw breaded chicken nuggets		36% (48/132)	25% (33/132)	26%(34/131)	29% (115/395)
Ground pork		23% (31/132)	4% (5/132)	1% (1/132)	9% (37/395)
Broiler chicken manure	Sample-level	25% (22/88) ↓	43% (51/120)	57% (73/128) ↓	43% (146/336)
	Farm-level	41% (9/22)	63% (19/30)	72% (23/32) ↓	61% (51/84)
Swine manure	Sample-level	22% (34/156)	7% (8/108)	NT	16% (42/264)
	Farm-level	54% (14/26)	22% (4/18)	NT	41% (18/44)
Turkey manure	Sample-level	60% (70/116)	NT	43% (50/116)	52% (120/232)
	Farm-level	83% (24/29)	NT	59% (17/29)	71% (41/58)
Feedlot beef manure	Sample-level	NT	4% (3/78)	NT	4% (3/78)
	Farm-level	NT	15% (2/13)	NT	15 % (2/13)
Irrigation water		NT	0% (0/32)	18% (18/100)	14% (18/132)
↑/↓Indicates a significant increase/decrease in prevalence compared to 2015; NT – not tested.

Figure 2.3 - Text Description

Figure 2.3: Distribution of Salmonella spp. serovars among food, animal and environmental samples, FoodNet Canada, 2016.

no data	Sample type
	Irrigation water	Feedlot beef manure	Turkey manure	Swine manure	Broiler chicken manure	Ground pork	Chicken breast	Frozen raw breaded chicken product
Salmonella Enteritidis	6%	67%	0%	0%	25%	3%	42%	42%
Salmonella Heidelberg	0%	0%	1%	0%	11%	0%	4%	17%
Salmonella Typhimurium	33%	0%	0%	5%	0%	8%	1%	3%
Other Salmonellaserovars	61%	33%	99%	95%	64%	89%	53%	40%

Figure 2.3 shows a stacked horizontal bar chart representing the percentage of all positive samples for selected Salmonella serovars: Enteritidis, Heidelberg, Typhimurium and Other. On the y-axis are the type of samples collected through retail, farm and environmental samples and the x-axis shows the percent of all Salmonella positive samples.

For a breakdown of the "Other" serovars, please refer to Table 2.3.

Table 2.3: Top 5 Salmonella spp. serovars identified in 2016 across the human (endemic), retail, farm and environmental surveillance components, by sentinel site, FoodNet Canada.

Human endemic cases	Retail			Farm				Irrigation water
	Chicken breast	Frozen breaded chicken	Ground pork	Broiler chicken	Swine	Beef cattle	Turkey
Ontario
(n=61)	(n=16)	(n=48)	(n=31)	(n=22)	(n=34)	no data	(n=70)	no data
Typhimurium (25%)	Kentucky (31.3%)	Enteritidis (31%)	Derby, Infantis (13% each)	Kentucky (27%)	Derby (35%)	No sampling conducted for this commodity	Muenchen (33%)	No sampling conducted
Enteritidis (23%)	Heidelberg (25.0%)	Infantis (15%)	Typhimurium, 4,[5],12:i:- (16% each)	Braenderup, Infantis (23% each)	Worthington, Typhimurium (18% each)		Albany (16%)
Heidelberg (11%)	Typhimurium (12.5%)	Heidelberg (13%)	Ohio (10%)	Enteritidis (18%)	4,[5],12:i:- (12%)		Agona (11%)
4,[5],12:i:- (7%)	Derby, Hadar, 4,[5],12:i:-, Infantis, Mbandaka (6.3% each)	Kentucky, Typhimurium (8% each)	Muenchen (7%)	Livingstone (9%)	Give, Infantis, Litchfield, Ouakam, Rissen, Uganda (3% each)		Bredeney (10%)
Muenchen, Newport (5% each)		Thompson (6%)	Brandenburg, Enteritidis, Give, Kentucky, Livingstone, Manhattan, Mbandaka, Worthington (3% each)				Scwarzengrund (7%)
British Columbia
(n=86)	(n=39)	(n=34)	(n=1)	(n=73)	no data	no data	(n=50)	(n=18)
Enteritidis (76%)	Enteritidis (41.0%)	Enteritidis (50%)	Rissen (100%)	Kentucky (40%)	No sampling conducted for this commodity	No sampling conducted for this commodity	Hadar (60%)	Typhimurium (33%)
4,[5],12:i:-, Typhimurium (5% each)	Kentucky (33.3%)	Heidelberg (21%)		Enteritidis (32%)			Agona (22%)	Agona (22%)
Agona, Braenderup, Cleveland, Hadar, Heidelberg, Infantis, Newport, Nima, Oranienburg, Paratyphi B var. Java, Saintpaul, Thompson, Weltevreden (1% each)	Infantis (15.4%)	Kentucky (12%)		Cubana, Liverpool (7% each)			Liverpool (8%)	Cubana, Derby, Diarizonae, Enteritidis, Hadar, Infantis, Liverpool, Senftenberg (6% each)
	Hadar, I,20:-:z6, Mbandaka, Thompson (2.6% each)	Infantis, Thompson (6% each)		Heidelberg, Johannesburg (6% each)			Senftenberg (6%)
		IIIA:48:g,z51:-, Typhimurium (3% each)		Typhimurium (3%)			Berta, Idikan (2% each)
Human endemic cases	Retail			Farm				Irrigation water
	Chicken breast	Chicken nuggets	Ground pork	Broiler chicken	Swine	Beef cattle	Turkey
Alberta
(n=151)	(n=38)	(n=33)	(n=5)	(n=51)	(n=8)	(n=3)	no data	no data
Enteritidis (56%)	Enteritidis (61%)	Enteritidis (46%)	Infantis (40%)	Heidelberg (24%)	Derby (75%)	Enteritidis (67%)	No sampling conducted for this commodity	No positive samples were identified
Infantis (7%)	Kentucky (16%)	Infantis (21%)	Derby, Kentucky, Muenchen (20% each)	Enteritidis (20%)	Mbandaka, Senftenberg (13% each)	Infantis (33%)
Heidelberg (5%)	Infantis (8%)	Heidelberg (18%)		Infantis (18%)
Typhimurium (5%)	Braenderup, Derby, Hadar, 4,[5],12:i:-, Mbandaka, Thompson (3% each)	Kentucky (6%)		Kentucky, Senftenberg (10% each)
4,[5],12:i:- (3%)		IIIA:48:g,z51:-, Schwarzengrund, Thompson (3% each)		Mbandaka (4%)

Salmonella Enteriditis

Salmonella Enteritidis (SE) is the most common serovar causing human illness in Canada. In 2016, 3,400 cases were reported to NESP, representing 44% of all reported human Salmonella infections^Footnote 2. Within the FoodNet Canada sentinel sites, SE is the main serovar observed among endemic cases of salmonellosis in the British Columbia (76%) and Alberta (56%) sentinel sites, while it ranks as the second most common serovar (after Typhimurium) among endemic cases in the Ontario sentinel site (23%) (Figure 2.4). As a result, the British Columbia and Alberta sites have much higher incidence rates of human endemic SE cases compared to the Ontario site.

Figure 2.4 - Text Description

Figure 2.4: Proportion of endemic human Salmonella spp. cases classified as S. Enteritidis and other serovars, FoodNet Canada.

Serovar	British Columbia							Ontario			Alberta
	2010	2011	2012	2013	2014	2015	2016	2014	2015	2016	2014	2015	2016
Enteritidis	50.00	67.95	41.82	54.84	56.12	53.66	75.58	33.33	30.61	22.95	54.76	57.32	56.00
Other	50.00	32.05	58.18	45.16	43.88	46.34	24.42	66.67	69.39	77.05	45.24	42.68	44.00

Figure 2.4 shows a stacked vertical bar chart representing the proportion of human endemic Salmonella spp. cases reported by each site and year for Enteritidis or other Salmonella serovars. On the y-axis is the proportion of endemic cases and the x-axis presents the sentinel site and year during which these cases were reported.

In 2016, there were a total of 54 international travel-related cases of SE across the sentinel sites. The majority of these cases (81%) travelled to the Americas (Central, South and Caribbean), with 61% reporting travel to Mexico, followed by the Dominican Republic and Cuba (Figure 2.5). Molecular subtyping has shown that SE acquired through international travel is different from the strains observed among domestically acquired cases. Furthermore, strains differ by country of travel and have also shown diversity within a country.

Figure 2.5 - Text Description

Figure 2.5: Region of travel reported in 2016 among Salmonella Enteritidis cases classified as international travel—related cases within FoodNet Canada sentinel sites.  (source: https://mapchart.net/world.html)

no data	United States of America	Americas (Central, South and Caribbean)	Europe	Asia	Mexico	Panama	Jamaica	Cuba	Dominican Republic	St. Lucia
Proportion of cases	6%	81%	2%	11%	61%	2%	5%	14%	16%	2%

This figure shows two pictures of the regions of the world with different perspectives. The first picture displays the global land mass and highlighted are the countries/regions that cases reported having traveled prior to their illness: United States of America, Americas (Central, South, and Caribbean), Europe and Asia. The second figure focuses on Mexico and Central American countries, with the following countries in color: Mexico, Nicaragua, Jamaica, Cuba and Dominican Republic. Each country/regions highlighted in these figures include the percentage of cases out of all the travel-related illnesses that reported having traveled to these countries/regions.

Between 2015 and 2016, the human incidence of SE in the British Columbia site increased, whereas the proportion of positive retail chicken breast and broiler chicken manure samples for SE decreased, and the proportion of positive frozen raw breaded chicken products remained the same. In contrast in the Alberta site, the proportion of SE identified in broiler chicken manure and frozen raw breaded chicken products samples remained the same with a slight decline in human incidence during these two years. However, the overall proportion of SE identified among retail chicken breast samples more than doubled, increasing significantly from 8% in 2015 to 17% in 2016 (Figure 2.6).

The distribution of chicken breast products across the country tends to be regionalized, with products processed through abattoirs remaining largely within that region for consumption. This knowledge allows us to better assess the trends observed in humans, retail and farm levels and to determine the impact that each has on the presence of SE observed. The strong regional component of food processing would suggest a relationship between what is found on food products and human illness.

In 2013 a multi-serovar vaccine (Enteritidis, Kentucky, Typhimurium, Heidelberg and Infantis) was introduced across farms in the province of Ontario to reduce the levels of SE^Footnote 3, and the impact of this intervention can be observed in the Ontario site data. Surveillance from "farm to fork" provides the information for evaluating the effect of introducing this vaccine on the presence of SE in broiler chickens, the presence of SE in retail chicken products and the impact on human incidence. Data collected in both Ontario sites, the Region of Waterloo and the Middlesex-London Health Unit, has shown that the proportion of broiler chicken manure samples positive for SE decreased from 7% in 2012 to 2% in 2013 to 0% in 2015. In 2016, only four broiler chicken manure samples (out of 88) collected were found to be positive with SE, representing half and a third of the proportion observed of SE in broiler chicken manure samples collected in the Alberta and British Columbia sites, respectively. Simultaneously, there were no positive samples identified among retail chicken breast in 2016, and the reported human incidence of SE is the lowest across all three sites. However, in 2016, 12% of all frozen raw breaded chicken products sampled in Ontario were found to be positive for SE, thereby contributing to the maintenance of the human incidence levels, together with other potential sources, such as eggs.

Although SE is primarily isolated from chicken manure and retail samples collected through FoodNet Canada, SE has also been identified in samples from irrigation water and ground pork samples collected from the sentinel sites. Although the occurrence of SE in these products (6% and 3% identified, respectively) is lower compared to chicken sources, these should still be considered possible sources of infection for endemic cases. In addition, there are other food products not currently sampled by FoodNet Canada that are also known to be sources of SE, particularly eggs. One of FoodNet Canada's main objectives is to collect information in order to evaluate the impact of any interventions implemented for pathogen reduction. As such, it is important to continue surveillance of products that are known to be a source of human infection, as well as to continue collecting enhanced case level information to determine the role that other food products have in the overall incidence of SE infections in Canada.

Figure 2.6 - Text Description

Figure 2.6: Human incidence rate (per 100,000 person-years) for endemic Salmonella Enteritidis cases and proportion of retail chicken samples, retail frozen raw breaded chicken products and broiler chicken manure samples positive for S. Enteritidis across FoodNet Canada's sentinel sites, 2011-2016a.

Sentinel site	Chicken breast – proportion of all tested			Frozen chicken products – proportion of all tested			Broiler chicken farms – proportion of all tested			Human incidence rates
no data	2014	2015	2016	2014	2015	2016	2014	2015	2016	2014	2015	2016
All sites	9%	10%	10%	12%	12%	12%	19%	13%	11%	8.62	7.62	8.19
Ontario	0%	1%	0%	19%	9%	11%	0%	0%	5%	3.05	3.15	2.91
British Columbia	14%	23%	12%	10%	14%	13%	40%	29%	18%	11.76	9.36	13.49
Alberta	10%	8%	17%	9%	12%	11%	8%	8%	8%	7.97	8.92	8.17

This figure consists of multiple graphs, one graph for each surveillance component: retail chicken breast, retail frozen chicken products, broiler chicken farms and human incidence rates. Each graph presents the proportion of samples positive for S. Enteritidis or the human annual incidence rate per 100,000 population for all sites combined and for each individual site. Different styles of lines have been used to describe the proportions or incidence rate for each individual site and all sites combined. The left y-axis presents the human incidence rate per 100,000 population or the proportion of samples positive for S. Enteritidis and the x-axis presents the year when the samples were collected.

Please note that in 2014 Ontario site data was collected in the Region of Waterloo from January to March with data collection beginning in August in the Middlesex-London Health Unit.

Other Salmonella serovars of interest

Over the last few years a fairly stable level of Salmonella prevalence has been observed within the food and animal samples collected across all three sentinel sites, as well as within the overall human incidence for salmonellosis (Figure 2.8). However, changes over time have been observed within the distribution of Salmonella serovars identified from these samples and cases, with different serovars being identified depending on the sampled commodity and sentinel site.

Salmonella Kentucky

Although Salmonella Enteritidis is the most common cause of human salmonellosis and the serovar most frequently isolated from poultry products, there are other serovars that are prominent among the food and animal samples collected under FoodNet Canada's surveillance activities that do not appear to cause a high burden of human disease (Figure 2.8). Within the poultry samples, S. Kentucky is the second most commonly isolated serovar, followed by S. Heidelberg and S. Typhimurium. While in 2016 S. Kentucky represented 16% of all Salmonella isolated from poultry samples (retail and farm), this serovar has only been reported once (2015) as the source of human endemic salmonellosis within the current sentinel sites and for 36 cases at the national level in 2016 to NESP^Footnote 2. This serovar can also be found within swine samples (retail and farm), but at much lower proportions (2% in 2016).

Salmonella Typhimurium (S. I 4,[5],12:i:1,2) and Salmonella I 4,[5],12:i:-

At the national level, S. Typhimurium and S. 4,[5],12:i:- ranked 2^nd and 6^th amongst the most common serovars causing human illness in 2016, respectively^Footnote 2. Within the FoodNet Canada sites, salmonellosis due to S. Typhimurium was the most common serovar reported among endemic cases in the Ontario sentinel site, while ranking 2^nd and 3rd of the most common serovars reported among endemic cases in the British Columbia and Alberta sites, respectively (Figure 2.7 and Table 2.3). In contrast, less than 5% of human salmonellosis is reported to be caused by S. 4,[5],12:i:- within these sites. Interestingly, these two serovars are the most commonly identified within the swine/pork samples collected through FoodNet Canada signaling that they could be contributing to salmonellosis caused by these serovars within the sentinel sites  (Figure 2.8).

Other potential sources for these organisms should also be considered when looking at possible risks for Canadians. In recent years, Canada has experienced cases of S. 4,[5],12:i:- and S. Typhimurium resulting from exposure to frozen feeder rodents, some of which were part of an international outbreak investigation^Footnote 4,^Footnote 5. The findings of these investigations underscore the importance of collecting enhanced case-level information in order to identify rare sources of exposure and have informed exposure questions included in FoodNet Canada's enhanced questionnaires to ensure that these risks continue to be monitored over time.

Figure 2.7 - Text Description

Figure 2.7: Proportion of endemic human Salmonella cases of S. Typhimurium compared to all other serovars, FoodNet Canada.

Serovar	British Columbia							Ontario				Alberta
	2010	2011	2012	2013	2014	2015	2016	2014	2015	2016	2014	2015	2016
Typhimurium	19.23	10.26	5.45	3.23	5.10	13.41	4.65	27.78	20.41	24.59	15.48	7.64	4.67
Other	80.77	89.74	94.55	96.77	94.90	86.58	95.35	72.22	79.59	75.41	54.52	92.36	95.33

Figure 2.7 shows a stacked vertical bar chart representing the proportion of human endemic Salmonella spp. cases reported by each site and year for Typhimurium or other Salmonella serovars. On the y-axis is the proportion of endemic cases and the x-axis presents the sentinel site and year during which these cases were reported.

Salmonella Heidelberg and Salmonella Infantis

As shown by the Salmonella recovery data from both retail and farm components, S. Heidelberg is primarily isolated from poultry samples as it was not identified among the salmonellae recovered from the swine or pork samples. When integrating both the human and non-human data, it is interesting to note the simultaneous decrease observed in the proportion of S. Heidelberg recovered from food or animal samples and the slight increase in the overall human disease incidence caused by this serovar (Figure 2.8). The proportion of all Salmonella isolates identified as S. Heidelberg among poultry samples has undergone a statistically significant decrease from 14% in 2014 to 8 % in 2016 (Figure 2.8). This decrease is mirrored by the reduction of the proportion of S. Heidelberg identified among all salmonellae recovered from frozen raw breaded chicken products, which decreased from 11% in 2014 to 5% in 2016. The decreases of S. Heidelberg identified among poultry samples could be a result of the introduction of the multi-strain vaccine to the poultry sector in 2013 in Ontario, which included protection against this serovar within the poultry flocks. However, within human cases, the overall incidence of S. Heidelberg had a slight increase from 0.3 to 0.8 cases per 100,000 person-years between 2014 and 2016, respectively, highlighting the need to continue monitoring known sources and looking for possible additional risks.

In 2016 the emergence of S. Infantis was observed across the human, food and animal sectors monitored through FoodNet Canada. While the incidence of disease caused by S. Infantis is much lower compared to the incidence of other common serovars, a slight increase in the overall incidence was observed between 2014 and 2016 (0.1 to 0.6 cases per 100,000 person-years). This increase is mainly due to an increase observed in the Alberta site, where the reported incidence for S. Infantis increased from 0.4 in 2015 to 1.0 cases per 100,000 person-years in 2016, while both the Ontario and British Columbia sites reported an incidence of 0.2 cases per 100,000 person-years in 2016. Increases have also been observed in the non-human data whereby the proportion of all salmonellae represented by S. Infantis increased from 3% in 2014 to 8% in 2016 among poultry samples and from 1% in 2014 to 9% in 2016 among swine samples (Figure 2.8). These increases have been observed within chicken manure samples (1% in 2014 to 4% in 2016 of all salmonellae) and chicken breast samples (0% in 2014 to 3% in 2016 of all salmonellae). Early in 2016, an outbreak investigation was undertaken to determine the source of S. Infantis which caused a total of 110 cases across nine provinces^Footnote 6. Epidemiological and laboratory information indicated that exposure to fresh, raw chicken was the likely source of these infections. Due to its emergence, it will be critical to continue to monitor the presence of S. Infantis across the food continuum to identify areas where food safety measures may be necessary to prevent its further spread and human illnesses.

Figure 2.8 - Text Description

Figure 2.8: Distribution of Salmonella serovars among all Salmonella spp. recovered from retail and farm samples combined, as well as the incidence of Salmonella infections and distribution of serovars causing endemic human illness, FoodNet Canada, 2014-2016

Serovar	All food and animal samples			Poultry			Swine			Human
	2013	2014	2015	2014	2015	2016	2014	2015	2016	2014	2015	2016
Enteritidis	17.64	28.57	27.05	36.42	30.12	25.95	0.00	0.00	1.27	54.84	53.50	51.74
4,[5],12:i:-	2.20	2.42	3.07	0.00	0.00	1.69	14.49	32.61	11.39	3.23	4.50	3.82
Heidelberg	15.63	11.38	9.63	14.20	10.59	8.44	0.00	0.00	0.00	16.13	2.00	3.82
Infantis	1.60	2.66	4.92	3.09	5.41	8.44	1.45	0.00	8.86	0.00	0.50	3.47
Kentucky	22.44	13.32	17.21	16.67	19.76	15.61	1.45	0.00	2.53	0.00	0.00	0.35
Typhimurium	3.41	5.81	6.56	1.85	4.71	2.11	24.64	23.91	13.92	3.23	11.50	11.46
Other serovars	37.07	35.84	31.56	27.78	29.41	37.76	57.97	43.48	62.02	22.58	28.00	25.35

This figure consists of multiple graphs, one graph for all food and animal samples, poultry farms, swine farms and human incidence rates. Each graph presents the proportion of samples positive for the different Salmonella serovars (Enteritidis, 4,[5],12:i:-, Heidelberg, Infantis, Kentucky, Typhimurium and the Other serovars group) or the human annual incidence rate per 100,000 population for all sites combined. Different colors have been used to describe the proportions for each type of sample and a solid black line has been sued for the incidence rate. For the graphs displaying information for "all food and animal samples", poultry, and swine, the left y-axis presents the proportion of all Salmonella recovered and right y-axis presents the proportion of all samples collected that were identified as one of the 8 different serovars groupings . For the human graph, the left y-axis represents the proportion of Salmonella cases while the right y-axis represents the incidence rate per 100,000 persons. All graphs have the year when the samples were collected represented along the x-axis.

Public health impact

There are over 2200 Salmonella serovars identified to date, some of which are species-specific and others that are zoonotic as they can be transmitted between humans and animals. Salmonella surveillance across the food chain allows us to identify possible sources of specific Salmonella serovars commonly found to cause human illness. In Canada, the top three Salmonella serovars, as reported by NESP, are Enteritidis, Typhimurium and Heidelberg^Footnote 2.

Surveillance conducted by FoodNet Canada has shown that the serovar prevalence varies depending on the region as the sentinel sites in both British Columbia and Alberta reported the majority of their endemic cases as SE, whereas in the Ontario site the most common serovar found in endemic cases was S. Typhimurium followed by SE. There is overlap between the common serovars identified in humans and across the food sector within these regions. In both British Columbia and Alberta, SE is the most common serovar recovered from retail and farm poultry samples while little to none is observed in ON. In contrast, in Ontario, S. Typhimurium is the most common serovar recovered from ground pork and swine farms, while little to none is observed in the other two sites.

While it is important to conduct surveillance at the national level, the information collected through FoodNet Canada has shown the value of regional representation to evaluate the differences that may exist not only on human illness but also in the possible sources of exposure. This knowledge is critical for determining the type of pathogen reduction programs that need to be implemented, as the type of program may vary depending on the food/animal sector and region in Canada.

Two interesting observations have become evident through the collection of Salmonella information across the food chain. First, recognizing that there are regional differences in the Salmonella prevalence and serovars identified within the chicken and pork commodities, it is important to note the differences within the serovars present at the farm and retail levels. In Ontario, while S. Kentucky was the primary serovar identified from both broiler chicken farms and retail chicken breast samples, other serovars identified in the farm samples were not identified within the positive retail chicken breast samples (Table 2.3). The identification of these other serovars at the retail level may represent the introduction of Salmonella serovars present in chicken breasts obtained from other Canadian regions or from international sources or simply due to the limited sampling (30 farms per year). Secondly, serovars that are highly prevalent in the food and animal sector, such as S. Kentucky within the poultry sector and S. Derby within the swine sector, do not appear to cause human illness within these sentinel sites. This is also supported by the small number of cases reported at the national level to NESP on an annual basis for these and other serovars.

Although not all of the Salmonella serovars have the same ability to cause human illness, it is important to conduct ongoing surveillance across the food chain to better understand trends over time. It is through the collection of surveillance data from farm to fork on an annual basis that provides public health the ability to identify emergent strains and to determine the source of this emergence, whether at the farm, abattoir or retail levels. This is demonstrated in this report with the provision of information for on-going (e.g. SE) and emerging (e.g. S. Infantis) food safety issues to assist in the evaluation and identification of areas requiring further attention.

Shigatoxigenic E. coli (STEC)

Human surveillance summary

Table 3.1: Incidence rates (per 100,000 person-years) of STEC by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	1.26	0.62	2.58	2.72	2.34	1.25	2.20	1.86
International travel	0.21	0.00	0.69	0.68	0.43	0.00	0.51	0.35
Outbreak	0.42	0.00	0.79	1.26	0.00	0.00	0.51	0.65
Non-endemic	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Lost to follow-up	0.00	0.00	0.30	0.29	0.00	0.00	0.15	0.15
Total	1.89	0.62	4.36	4.96	2.76	1.25	3.37	3.01

Figure 3.1 - Text Description

Figure 3.1: Relative proportion of STEC by case classification.

Case classification	Number of cases	Relative proportion
Endemic	37	62%
Lost to follow-up	3	5%
Outbreak	13	22%
Travel	7	12%

Figure 3.1 shows a pie chart of the relative proportion of STEC cases in the FoodNet Canada surveillance system by case classification of endemic, lost to follow-up, outbreak and travel) for 2016. The chart includes the case classification, the number of cases and the relative proportion.

Figure 3.2 - Text Description

Figure 3.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic STEC cases within FoodNet Canada sentinel sites, 2016.

Age category	Female	Male	Overall total (all genders combined)
0 to 4	13.778	9.834	11.757
5 to 9	0.000	1.644	0.852
10 to 14	0.000	3.541	1.825
15 to 19	7.218	5.095	6.124
20 to 24	4.570	0.000	2.201
25 to 29	1.351	0.000	0.673
30 to 39	0.000	0.000	0.000
40 to 59	2.130	0.000	0.911
60+	0.959	1.082	1.017
Overall total (all ages combined)	2.318	1.401	1.858

Figure 3.2 shows a bar chart of the annual incidence rate of STEC per 100,000 peron-years by overall total age category and by age category and gender for 2016. The y-axis presents the incidence rate per 100,000 population and the x-axis presents the age categories. The bars represent the total incidence for all genders by age group as well as the total incidence of male and female separately by age category.

Food, animal and environmental surveillance summary

Table 3.2: Prevalence of STEC spp. in 2016 by commodity and FoodNet Canada sentinel site.

Sample type		Ontario site	Alberta site	British Columbia site	All sites
Ground beef		1.5% (2/131)	0% (0/131)	2.3% (3/131)	1.3% (5/393)
Feedlot beef manure	Sample-level	NT	10% (8/78)	NT	10% (8/78)
	Farm-level	NT	54% (7/13)	NT	54% (7/13)
Irrigation water		NT	47% (15/32)	24% (26/110)	29% (41/142)
↑/↓Indicates a significant increase/decrease in prevalence compared to 2015; NT: not tested.

Public Health Impact

Shigatoxigenic Escherichia coli are a specific group of E. coli organisms categorized based on their presence of shigatoxins. Since implementation of all three current FoodNet Canada sentinel sites a stable prevalence of non-O157 STEC in retail, farm, and water samples, with few O157:H7 strains identified, has been found. In contrast, nearly three quarters of all human cases of STEC reported to FoodNet Canada were identified as E. coli O157:H7. This difference may be partially influenced by testing practices conducted by public health laboratories in the identification of O157 isolates in comparison to other STEC subtypes. Although there are over 200 different non-O157 subtypes that have been associated with human illness^Footnote 7, six of these have been prioritized with regards to human health: serogroups O26, O45, O103, O111, O121 and O145^Footnote 8. In FoodNet Canada surveillance, serogroups O26, O103 and O121 were identified among human cases and irrigation water, while only O103 was identified among the retail ground beef samples. Through comparison of FoodNet Canada retail and human samples, non-O157 STEC is observed throughout the year in both streams, with a potential seasonality in the spring and summer months (Figure 3.3). While clinical labs routinely test for STEC O157, few clinical laboratories routinely test for non-O157 STEC resulting in under-detection of these pathogens. Additionally, even when non-O157 STEC are identified, further subtyping is not always conducted.

In more recent years, clinical laboratories have introduced the use of culture independent diagnostic tests (CIDT), which are PCR-based tests used for the rapid identification of one or more organisms. Although the use of these CIDTs provides timely results for the clinician to treat patients, it does not provide an isolate to conduct further subtyping or other molecular tests required for surveillance and outbreak detection purposes. This may cause issues for identifying non-O157 STEC subtypes further, as currently PCR-based methods are routinely only used to identify O157 STEC. A lack of more discriminatory subtyping information has been observed through NESP which in 2016 reported an increase in E. coli non-O157 reports without additional sub-typing information to 56% in 2016^Footnote 2. The increased use of CIDTs for the detection of STEC without reflex culture will exacerbate current issues, with concern to further non-O157 subtyping, and hinder the ability to monitor trends in non-O157 cases over time. Ability to identify potential outbreaks, whether local or multi-jurisdictional may also become difficult when subtype information is limited, or not able to be produced by reflex culture. FoodNet Canada will continue to monitor if these trends appear in data contributed to the program.

Although a small proportion of FoodNet Canada food samples were found to be positive with non-O157 STEC, these products should still be considered as a potential source of human illness for these subtypes in Canada. Both O157 and non-O157 STEC were also found in feedlot beef manure and irrigation water samples, representing potential environmental sources of exposure. Continued collection of thorough case-exposure information will help to identify other possible sources that are not currently captured through surveillance programs or that are emergent. For example, a new source of non-O157 STEC was identified in December of 2016 through a multi-jurisdictional outbreak investigation. Based on information collected from cases, flour was identified to be the source of infection^Footnote 9. It is for this reason that continued efforts are needed at both human and food/animal laboratories to further identify the subtypes for STEC isolates to better understand which STEC subtypes are causing human illness, which sources are most commonly found to contain these subtypes, and how different is the burden of disease associated with these subtypes. This information would be needed to evaluate programs implemented to reduce STEC in specific sectors, but to also prioritize STEC subtypes for surveillance, regulatory, and policy purposes.

Table 3.3: Timeline of 2016 non-O157 STEC in FoodNet Canada retail samples, human cases, and outbreaks.

Season	Ontario sentinel site		Alberta sentinel site		British Columbia sentinel site		National outbreaks
	Human cases	Retail samples	Human cases	Retail samples	Human cases	Retail samples	no data
Winter (January-March)	no data	no data	no data	no data	OROUGH:h35	O103:h3/O5:NM	no data
Spring (April-June)	no data	no data	O26:h21 O26:h21	no data	O121:h2	no data	no data
Summer (July-September)	no data	O76:h29 O76:NM	O121:h29 O103:h3	no data	O117:H7 O117:H7	O177:NM O8:h29	no data
Fall (October-December)	no data	no data	no data	no data	O5:NM	no data	Dec 29: STEC O121 Outbreak

Table 3.3 shows a seasonal timeline of non-O157 VTEC reported through the FoodNet Canada retail and human components, and the Outbreak Management Division. The timeline is represented by four seasons, winter, spring, summer, and fall. Circular icons represent retail isolates of non-O157, triangular icons represent human cases of non-O157, and a text box indicates the national STEC O121 outbreak.

Listeria Monocytogenes

Table 4.1: Incidence rates (per 100,000 person-years) of Listeria monocytogenes by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	0.00	0.00	0.10	0.19	0.00	0.21	0.05	0.15
Travel	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Outbreak	0.00	0.42	0.00	0.00	0.00	0.00	0.00	0.10
Non-endemic	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Lost to follow-up	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Total	0.00	0.42	0.10	0.19	0.00	0.21	0.05	0.25

Significant changes in endemic, travel, and total incidence rates:

• There were no significant changes from 2015 to 2016

Table 4.2: Prevalence of Listeria monocytogenes in 2016 by commodity and FoodNet Canada sentinel site.

Commodity	Ontario site	Alberta site	British Columbia site	All sites
Chicken breast	18% (24/131)	14% (18/132)	33% (44/132) ↑	22% (86/395) ↑
Ground beef	24% (32/132)	13% (17/132)↓	26% (39/132)	22% (88/396)
Frozen raw breaded chicken products	16% (21/132)	14% (18/132)	13% (17/131)	14% (56/395)
Ground pork	24% (32/132)	6% (8/132)	14% (18/132)	15% (58/396)
Ready to eat slaws	0% (0/210)	0% (0/210)	0.5% (1/205)	0.2% (1/625)
↑/↓Indicates a significant increase/decrease in prevalence compared to 2015.

Public health impact

In Canada it is estimated that each year about one in eight Canadians (four million people) experience an episode of domestically acquired foodborne illness, of which 178 would be attributed to Listeria monocytogenes10. Although invasive listeriosis is a rare disease, it can result in severe symptoms such as sepsis, encephalitis, and meningitis^Footnote 11. Those most vulnerable to infection include the elderly or immunocompromised individuals, as well as pregnant women and their unborn children^Footnote 12. Listeria is more likely to cause death than other foodborne bacteria, with approximately 20-30% of high risk cases dying from this infection^Footnote 13.

Although the incidence of invasive listeriosis across all three sentinel sites was low in 2016 (0.25 cases per 100,000 person-years), there were two outbreaks identified in Canada in that same year. In January 2016 the Canadian Food Inspection Agency (CFIA) conducted a recall of packaged salad products produced in the United States^Footnote 14. This led to the identification of 14 cases across the Eastern Canadian provinces in addition to the 19 cases identified across the United States. This outbreak was later followed by a recall of chocolate milk products in Ontario as they were linked to an outbreak of listeriosis cases in that same province^Footnote 15.

Due to the severity of disease and the high risk to vulnerable populations, surveillance of Listeria monocytogenes along the food continuum is important for identifying potential sources of illness. In 2016, retail sampling consisted of raw meat products (chicken breast, ground pork and beef) and ready to eat slaws. After a significant increase in the recovery of Listeria monocytogenes from ground beef samples was observed in 2015 compared to 2014 in the FoodNet Canada Alberta and British Columbia sentinel sites, a decrease in prevalence to previous levels was observed in Alberta in 2016 while still remaining high in samples purchased within the British Columbia sentinel site. Prevalence of L. monocytogenes has remained relatively stable in ground beef sampled in Ontario. All retail products were sampled from either an independent shop, such as butcher shops, or from chain grocery stores to better understand risks associated with different types of retail establishment. In 2016, the prevalence of L. monocytogenes recovered from ground beef and ground pork samples collected at independent shops were significantly higher when compared to the L. monocytogenes prevalence from these types of samples purchased at chain stores. The reasons for this are not well understood. It is possible that, due to processing in-store, opportunities for cross-contamination are increased at independent butcher shops during processing steps, as this difference is not seen in less processed meat products like chicken breast. Although raw meat products were found to be contaminated with Listeria monocytogenes, it should be noted that the majority of outbreaks and sporadic cases are predominantly associated with ready to eat products or contaminated produce. However, this trend in Listeria presence on ground meats sampled from independent shops can indicate potential opportunities of cross-contamination of other pathogens.

Listeria monocytogenes is sensitive to heat treatment and can be removed through proper cooking processes^Footnote 16. As such, one must always follow cooking instructions, verify internal temperatures after cooking raw meat products, and ensure that all bowls, utensils and surfaces are washed with hot water and soap to prevent further cross-contamination. The presence of Listeria monocytogenes in cooked products can be attributed to cross-contamination after processing or during storage and handling^Footnote 17.

Table 4.3: Comparison of Listeria monocytogenes prevalence in samples collected at independent stores and chain grocery stores, FoodNet Canada 2016.

no data	Store Type
no data	Independent stores	Chain grocery stores
Chicken breast	22%	22%
Ground beef	30%	20%
Ground pork	33%	11%

Yersinia

Table 5.1: Incidence rates (per 100,000 person-years) of Yersinia cases by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	0.42	0.62	1.29	1.95	4.68	9.34 ↑	1.89	3.41 ↑
Travel	0.42	0.00	0.40	0.68	0.64	1.66	0.46	0.75
Outbreak	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Non-endemic	0.00	0.00	0.00	0.00	0.00	0.21	0.00	0.05
Lost to follow-up	0.21	0.42	0.30	0.39	0.43	2.70	0.31	0.95
Total	1.05	1.04	1.98	3.02	5.74	13.91 ↑	2.66	5.17 ↑
↑/↓Indicates a significant increase/decrease in incidence compared to 2015. AB site does not include or follow-up Yersinia Intermedia cases.

Figure 5.1 - Text Description

Figure 5.1: Relative proportion of Yersinia by case classification.

Case classification	Number of cases	Relative proportion
Endemic	68	66%
Lost to follow-up	19	18%
Non-endemic	1	1%
Travel	15	15%

Figure 5.1 shows a pie chart of the relative proportion of Yersinia cases in the FoodNet Canada surveillance system by case classification of endemic, lost to follow-up, non-endemic and travel) for 2016. The chart includes the case classification, the number of cases and the relative proportion.

Figure 5.2 - Text Description

Figure 5.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic Yersinia cases within FoodNet Canada sentinel sites, 2016.

Age category	Female	Male	Overall total (all genders combined)
0 to 4	1.72	9.83	5.88
5 to 9	1.77	6.58	4.26
10 to 14	0.00	3.54	1.82
15 to 19	0.00	6.79	3.50
20 to 24	3.05	1.42	2.20
25 to 29	4.05	1.34	2.69
30 to 39	3.97	3.94	3.95
40 to 59	2.98	2.50	2.55
60+	4.32	4.33	4.32
Overall total (all ages combined)	2.92	3.90	3.41

Figure 5.2 shows a bar chart of the annual incidence rate of Yersinia per 100,000 person-years by overall total age category and by age category and gender for 2016. The y-axis presents the incidence rate per 100,000 person-years and the x-axis presents the age categories. The bars represent the total incidence for all genders by age group as well as the total incidence of male and female separately by age category.

Public health impact

The BC site incidence rates for both endemic and total cases of yersiniosis have significantly increased since 2016. This is due to changes in laboratory method protocols introduced in June 2016, which increased the detection of this organism by using cold enrichment together with protocols stating that all stool samples were to be tested for the presence of Yersinia. Currently, Yersinia is not a nationally-notifiable disease, and so the annual national incidence rate is not available for comparison. Yersiniosis appears to be predominantly a domestically-acquired infection, as demonstrated by the low proportion of travel-related cases (15%).

It is not clear what role food and animals have on the incidence of human yersiniosis. In 2010, FoodNet Canada discontinued the testing for Yersinia on retail pork due to low prevalence of human-pathogenic strains. Similarly, Yersinia testing was stopped across all commodities in the farm component in 2012 due to low prevalence detected. In previous years, Yersinia was detected in untreated surface water collected in the FoodNet Canada sentinel sites, but was also identified as non-pathogenic. Therefore, it is important to continue collecting enhanced case level information on Yersinia cases to determine the sources that may be contributing to human infections in Canada.

Shigella

Table 6.1: Incidence rates (per 100,000 person-years) of Shigella by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	0.00	0.83	0.40	0.88	1.28	0.62	0.51	0.80
Travel	0.63	0.62	1.68	0.78	1.49	1.25	1.38	0.85
Outbreak	0.00	0.00	0.00	0.00	0.21	0.00	0.05	0.00
Non-endemic	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Lost to follow-up	0.21	0.00	0.20	0.00	0.85	0.00	0.36	0.00
Total	0.84	1.45	2.28	1.65	3.83	1.87	2.30	1.66

Figure 6.1 - Text Description

Figure 6.1: Relative proportion of Shigella by case classification.

Case classification	Number of cases	Relative proportion
Endemic	16	48%
Travel	17	52%

Figure 6.1 shows a pie chart of the relative proportion of shigellosis cases in the FoodNet Canada surveillance system by case classification of endemic and travel for 2016. The chart includes the case classification, the number of cases and the relative proportion of cases.

Figure 6.2 - Text Description

Figure 6.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic Shigella cases within FoodNet Canada sentinel sites, 2016.

no data	Gender
Age category (years)	Female	Male	Overall total (both genders combined)
0-4	1.72	1.64	1.68
5-9	5.31	1.64	3.41
10-14	0.00	1.77	0.91
15-19	0.00	0.00	0.00
20-24	1.52	1.42	1.47
25-29	2.70	1.34	2.02
30-39	0.00	0.66	0.33
40-59	0.85	0.00	0.36
60+	0.00	0.54	0.25
Overall Total (all ages combined)	0.91	0.70	0.80

Figure 6.2 shows a bar chart of the annual incidence rates of endemic shigellosis (per 100,000 person-years) cases by overall total age category and both genders combined, as well as by each age category and gender within all FoodNet Canada sentinel sites combined for 2016. The y-axis presents the incidence rate per 100,000 person-years and x-axis presents the age categories. The bars represent the total incidence for all genders by age category as well as the total incidence of male and female separately by age category.

Public health impact

Travel is an important source of Shigella among human cases in 2016. Asia and the Americas (Central, South and Caribbean) were the most frequently reported travel destinations. Shigella is primarily transmitted through direct contact with an infected person or by ingestion of contaminated food or water. Historically, FoodNet Canada retail testing found Shigella bacteria on one sample of bagged leafy greens using PCR methods, but did not yield a positive by culture, therefore viability could not be determined^Footnote 18. Continued collection of enhanced case level information on Shigella cases is important to determine the sources that may be contributing to human infections in Canada.

Parasites and viruses

Giardia

Table 7.1: Incidence rates (per 100,000 person-years) of Giardia by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	5.87	3.74	4.46	6.42	5.53	4.15	5.06	5.22
Travel	1.89	1.45	3.47	3.11	2.34	3.32	2.81	2.76
Outbreak	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Non-endemic	0.42	0.00	2.08	2.24	0.85	1.25	1.38	1.46
Lost to follow-up	2.73	2.91	0.69	1.46	1.49	1.87	1.38	1.91
Total	10.91	8.10	10.70	13.23	10.21	10.59	10.63	11.35

Figure 7.1 - Text Description

Figure 7.1: Relative proportion of Giardia by case classification.

Case classification	Number of cases	Relative proportion
Endemic	104	46%
Lost to follow-up	38	17%
Non-endemic	29	13%
Travel	55	24%

Figure 7.1 shows a pie chart of the relative proportion of giardiasis cases in the FoodNet Canada surveillance system by case classification of endemic, lost to follow-up, non-endemic and travel for 2016. The chart shows the number of cases and the relative proportion in percent, by case classification.

Significant changes in endemic, travel, and total incidence rates:

• There were no significant changes from 2015 to 2016

Clinical profile (endemic cases only):

• Most commonly reported symptoms:
  • Diarrhea: 84%
  • Abdominal pain: 65%
  • Fatigue: 63%
  • Malaise: 55%
  • Weight loss: 53%
• Indicators of severity:
  • Bloody diarrhea: 11%
  • Emergency room visits: 20%
  • Hospitalizations: 6%
  • Antimicrobial prescriptions: 73%

Figure 7.2 - Text Description

Figure 7.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic Giardia cases within FoodNet Canada sentinel sites, 2016.

Age category	Female	Male	Overall total (all genders combined)
0 to 4	10.33	4.92	7.56
5 to 9	1.77	11.51	6.82
10 to 14	3.76	1.77	2.74
15 to 19	0.00	1.70	0.88
20 to 24	1.52	4.25	2.94
25 to 29	4.05	12.06	8.07
30 to 39	6.61	9.85	8.23
40 to 59	2.56	8.23	5.28
60+	2.40	4.33	3.31
Overall total (all ages combined)	3.43	7.01	5.22

Figure 7.2 shows a bar chart of the annual incidence rate of giardiasis per 100,000 person-years by age category and gender for 2016. The y-axis presents the incidence rate per 100,000 person-years and the x-axis presents the age categories and gender combinations. There are three bars side-by-side for each age group: a bar representing females, a bar representing males and a bar representing the overall incidence of both genders combined. Age categories are defined by a range of years.

Cryptosporidium

Table 8.1: Incidence rates (per 100,000 person-years) of Cryptosporidium by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	1.89	1.25	2.58	3.79	0.85	1.45	1.99	2.61
Travel	1.26	0.00 ↓	0.99	1.07	0.64	0.21	0.97	0.60
Outbreak	0.00	0.00	0.00	0.49	0.00	0.00	0.00	0.25
Non-endemic	0.00	0.00	0.00	0.10	0.00	0.00	0.00	0.05
Lost to follow-up	0.42	0.21	0.30	0.49	0.21	0.00	0.31	0.30
Total	3.57	1.45 ↓	3.86	5.93 ↑	1.70	1.66	3.27	3.82
↑/↓Indicates a significant increase/decrease in incidence compared to 2015.

Figure 8.1 - Text Description

Figure 8.1: Relative proportion of Cryptosporidium by case classification.

Case classification	Number of cases	Relative proportion
Endemic	52	68%
Lost to follow-up	6	8%
Non-endemic	1	1%
Outbreak	5	7%
Travel	12	16%

Figure 8.1 shows a pie chart of the relative proportion of cryptosporidiosis cases in the FoodNet Canada surveillance system by case classification of endemic, lost to follow-up, non-endemic, outbreak, and travel for 2016. The chart shows the number of cases and the relative proportion in percent, by case classification.

Significant changes in endemic, travel, and total incidence rates:

• There were significant decreases in the ON site travel and total incidence rates from 2015 to 2016.
• There was a significant increase in the AB site total incidence rate from 2015 to 2016.

Clinical profile (endemic cases only):

• Most commonly reported symptoms:
  • Diarrhea: 100%
  • Abdominal pain: 77%
  • Anorexia: 69%
  • Vomiting: 65%
  • Nausea: 62%
• Indicators of severity:
  • Bloody diarrhea: 13%
  • Emergency room visits: 62%
  • Hospitalizations: 8%
  • Antimicrobial prescriptions: 21%

Figure 8.2 - Text Description

Figure 8.2: Age and gender specific incidence rates (per 100,000 person-years) for endemic Cryptosporidium cases within FoodNet Canada sentinel sites, 2016.

Age category	Female	Male	Overall total (all genders combined)
0 to 4	8.61	13.11	10.92
5 to 9	5.31	13.15	9.37
10 to 14	0.00	1.77	0.91
15 to 19	1.80	3.40	2.62
20 to 24	4.57	5.66	5.14
25 to 29	4.05	6.70	5.38
30 to 39	3.97	0.00	1.98
40 to 59	0.43	0.36	0.36
60+	0.00	0.54	0.25
Overall total (all ages combined)	2.22	3.00	2.61

Figure 8.2 shows a bar chart of the annual incidence rate of cryptosporidiosis per 100,000 person-years by age category and gender for 2016. The y-axis presents the incidence rate per 100,000 person-years and the x-axis presents the age categories and gender combinations. There are three bars side-by-side for each age group: a bar representing females, a bar representing males and a bar representing the overall incidence of both genders combined. Age categories are defined by a range of years.

Cyclospora

Table 9.1: Incidence rates (per 100,000 person-years) of Cyclospora by case classification and FoodNet Canada sentinel site, 2016 (with 2015 shown for reference).

no data	Ontario site		Alberta site		British Columbia site		All sites
	2015	2016	2015	2016	2015	2016	2015	2016
Endemic	0.21	0.21	0.00	0.00	0.00	0.21	0.05	0.10
Travel	1.26	0.62	0.20	0.29	1.28	1.45	0.72	0.65
Outbreak	0.21	0.42	0.00	0.00	0.00	0.00	0.05	0.10
Non-endemic	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Lost to follow-up	0.00	0.21	0.00	0.00	0.00	0.00	0.00	0.05
Total	1.68	1.45	0.20	0.29	1.28	1.66	0.82	0.90

Figure 9.1 - Text Description

Figure 9.1: Age and gender specific incidence rates (per 100,000 person-years) for endemic Cryptosporidium cases within FoodNet Canada sentinel sites, 2016.

Case Classification	Number of cases	Relative proportion
Endemic	2	11%
Lost to follow-up	1	6%
Outbreak	2	11%
Travel	13	72%

Figure 9.1 shows a pie chart of the relative proportion of cyclosporiasis cases in the FoodNet Canada surveillance system by case classification of endemic, lost to follow-up, outbreak, and travel for 2016. The chart shows the number of cases and the relative proportion in percent, by case classification.

Retail sampling summary

Parasites

In 2016, parasites were tested for on ready-to-eat slaws and vegetables by FoodNet Canada. A single coleslaw sample (1/608) was positive for Cryptosporidium hominis; two coleslaw samples (2/625) were positive for Cyclospora cayetanensis; and 8 samples (8/611), 7 coleslaw and 1 baby carrot, were positive for Giardia. All positive samples were imported samples from the United States with the exception of one coleslaw sample which had a noted country of origin as the United States and Canada. Since PCR methodologies were used for the detection of parasites, the viability of these detected pathogens and the subsequent potential risk to consumers is unknown.

Viruses

In 2016, FoodNet Canada tested for viruses among sampled retail ready-to-eat slaws and vegetables. Among all samples tested, none (0/625) were found to be positive for viruses (Norovirus, Rotavirus, Hepatitis A, and Hepatitis E). Human cases of viruses are not reported to FoodNet Canada by the sentinel sites.

Public health impact

Compared with Giardia and Cryptosporidium, the majority of Cyclospora cases in 2016 were found to be travel-associated. Among the travel cases, the majority (77%) reported travel to the Americas (Central, South and Caribbean) region. Travel to Mexico was most commonly reported (90%) among cases that travelled to the Americas region. All cases that travelled to Mexico travelled between May and August, with the majority reporting travelling to Mexico's east coast. This is consistent with what was observed in 2015 and also internationally during this time period^Footnote 19,^Footnote 20. Since travel is a major contributor to Cyclospora cases in Canada, ongoing public health education regarding travel is important to help keep Canadians safe while travelling to countries where Cyclospora is endemic.

Appendix A — Non-human sample types tested in 2016

Non-human sample types tested in 2016

Site	Retail	Farm	Water
British Columbia	Ground beef, skinless chicken breast, frozen raw breaded chicken products, ground pork, ready-to-eat slaws & vegetables	Broiler chickens, turkey	Five sampling locations in the Sumas & Matsqui irrigation canals
Alberta	Ground beef, skinless chicken breast, frozen raw breaded chicken products, ground pork, ready-to-eat slaws & vegetables	Broiler chickens, swine, & feedlot beef	Eight sampling locations in the Western Irrigation District
Ontario	Ground beef, skinless chicken breast, frozen raw breaded chicken products, ground pork, ready-to-eat slaws & vegetables	Broiler chickens, swine, turkeys & layers	no data

Appendix B — Abbreviations and references

Abbreviations

AB

Alberta

BC

British Columbia

CIDT

Culture Independent Diagnostic Tests

CIPARS

Canadian Integrated Program for Antimicrobial Resistance Surveillance

ER

Emergency Room

NESP

National Enteric Surveillance Program

NT

Not Tested

ON

Ontario

PCR

Polymerase Chain Reaction

PHAC

Public Health Agency of Canada

SE

Salmonella Enteritidis

ST

Shigatoxin

STEC

Shigatoxigenic Escherichia coli

US

United States