Developing Country Perspective : a Caribbean Regional (CAREC) and Country viewpoint

1. Developing Country Perspective: a Caribbean Regional (CAREC) and Country viewpoint National Food Safety Strategy Symposium, Guelph, Ontario. March 21-23, 2005 Lisa Indar Program Manager Foodborne Disease Prevention and Control Caribbean Epidemiology Centre (CAREC/PAHO/WHO)

2. Overview • Background: CAREC • Importance of having a national approach to food safety : regional (at CAREC) and at country level • Drivers for developing national food safety strategies • Challenges in implementing new food safety strategies • Current and future food safety related activities • Best practices in areas of food safety seen applied • How communication, harmonization & integration among food safety stakeholders across Canada be improved

3. What is CAREC? mission:To improve the health status of Caribbean people by improving country capacity in epidemiology, laboratory and related public health disciplines, through programs of service, training and technical cooperation • A public health information, service & consulting organisation • Caribbean’s health monitoring & disease prevention agency • the PHAC /CDC for the Caribbean • Serves and acts on behalf of 21 member countries (CMCs) • A PAHO/WHO centre in the Americas • Directing Council and Scientific Advisory Committee • Multi Lateral & Bilateral Agreements;US$8M budget, 130 staff • 30 regional and international partners

4. CAREC’s Programs • Surveillance and Response; includes mortality data • Laboratory diagnostic and reference service; Lab QA • Information, Training, Research • Food, water and vector borne disease prevention • Immunization program coordination • Special Program on Sexually Transmitted Infections • Travel & Health (Quality Tourism for Caribbean (QTC)) • Non Communicable Disease, Injury & Substance Abuse Prevention

5. GUADELOUPE FR. GUIANA CMCs: CAREC Member Countries

6. STRATIFICATION OF CMCs BY SIZE Haiti and DOR not members but participate in selected programmes

7. CAREC agency collaborations Regional Agencies • CARICOM, CFNI, CEHI, CHA, ICCA, CAST, CROSQ, Bureau of Stds; CPC, UWI International agencies Health Canada, CDC, WHO, INPPAZ, FDA, FAO, U. of Ottawa

8. Canada-CAREC Collaboration • CAREC Council membership, since inception in 1975 • IDRC - Past grant on injury surveillance • CIDA (major signatory to CAREC/SPSTI Partners MOU) • HIV/AIDS, current grant 5 yrs, $8M • Health Canada (PHAC) • Signed letter of intent (2002); need to flesh out • Int’l Outbreak investigation agreement; would like clearer protocol • Food Safety, H Canada BPB, IPH/McLaughlin Centre/U of O • Priority areas of collaboration over next 3 years • Travel related protocol • Research and training (GSS, BOI) • NCDs/BRFS, HC BPB; St Lucia • Injury surveillance, HC BPB, U of O/IPH, - project at San F’do Hosp, T&T • Health Mapping- Centre for Surv Coord, Foodborne, Waterborne & Zoonones • Public Health Leadership & Workforce capacity building • Michener Institute • training course in lab. M’ment (EU funding); grant appl. for cervical cancercytology • QMPLS: 10 years of support in lab proficiency testing in our 21 CMCs

9. Safe, Happy, Healthy, More Productive People, Living in Harmony with Each other in Cleaner and Greener Environments Caribbean Health Vision Caribbean Cooperation in Health Initiative

10. Contextual Issues • Each CMC: own political governance; varying capacity, & priorities • Globalization – AIDS, SARS, food supply, global warming, partnerships, ICT, behaviors, travel and tourism • Increasing number of actors in international health • Changing expectations of population • Social determinants of health, poverty and alienation • Demographic changes • Environment degradation trends • Health of increasing importance in development “The health of the region is the wealth of the region”, Nassau Declaration of the CARICOM Heads of Government, 2001 • Knowledge we do have not sufficiently applied

11. Caribbean Travel & Tourism, 2002-most tourism dependant region in the world • 20 million stay-over arrivals • 14 million cruise ship arrivals CAREC/PAHO/WHO

12. Health Issues in Caribbean Tourism Industry • Outbreaks of foodborne diseases, legionnaires’ disease have cost more than $US200 million • Direct and indirect losses from cancellations in property and destination; latter harder to measure • Indirect losses from lawsuits • Difficult to measure effect of non-bookings from general perception of destination or Caribbean (safety, health, environment issues) or more global concerns (SARS, wars, BT)

13. Foodborne Diseases in the Caribbean • Major cause of economic burden, illness & death • 1989-2003: FBD increased >300%, 607- 3100 cases • GE in < 5 years: 1981-’99: 24,000 to 31,000 cases • GE in > 5 years:’94-2000: 7000 to 24,000 cases • 1990-2003: 73 outbreaks: 33 viral, 43 bacteria • 48% were FBD due to Salmonella (mainly SE) • Increase in hotels and cruise ship FBD outbreaks: visitors • 2002: 4 hotels, 10 cruise ships FBD outbreaks source: surveillance data at CAREC

16. Reported Human cases of SE Infections in the Caribbean, by Country, 1985-2000

17. Importance of having a national approach to food safety Regional food safety program (at CAREC) • Increasing prevalence and Impact of FBD: need to prioritize • WHO/PAHO priority, CCH2 priority, • Many small countries, varying capacities, working together-CCH • Many regional and int. agencies, sectors involved • Integrated coordinated approach: Link all stakeholders (CMCs, Agencies) • Common objectives :WTO, CARICOM, CSME, tourism, trade • Shared services: CAREC reference lab, Epi & other tech. services • Regional integration initiative • Regional focus and prioritizing of Food safety

18. Importance of having a national approach to food safety • Globalization • Tourism: Protect health of visitors; ensure sustainability of industry • Trade: facilitate int. trade of foods;Meet WTO/SPS requirements • Collective monitoring approach- trade, tourism, int. linkages • Caribbean voice at int. forum: CAREC act on behalf of CMCs • Regional policy and guidelines on enforcement • Societal factors (poverty, pop. growth, migration)

19. Importance of having a national approach to food safety Country Level • Own political governance • Enforcement and certification, prioritizing is at country level • Varying capacity, priorities • Coordination and Synergy: intersectoral, interagency • Integrate stakeholders from farm to table: • epidemiology, laboratory, environ. health, veterinary, policy, legislation • MOA, MOH, UWI, regional and int. agencies • Rapid Explosion/increases in in last 5 yrs • restaurant and street vendors • Mass catering (homes, small and large restaurants) • Tourism • Varying Cultural practices • Persistent poverty in some countries

20. Drivers for developing national food safety strategies • Globalization of markets; WTO SPS and TBT agreements -imply and necessitate countries to strengthen their food safety systems Conform national food regulations to International standards • Sub-regional policies: CCH2, PAHO, WHO, CARICOM, CSME, • Farm to table approach to food safety. • Tourism- economic dependency, int. links, travel advisory, high degree of concern for safety and security • Trade- agriculture, fisheries, high imports, issue of C’bean dumping • Epi situation in CMCs: Increase in FBD and outbreaks-locals & visitors • Economic impact • Festivals : carnival, cricket • Local concerns

21. As signatories to the WTO, CARICOM countries are expected to harmonize national and regional standards with standards at the international level in imports and exports of food products and adopt the WTO approach to improving food safety

22. Challenges faced in implementing new food safety strategies Because the region is characterized by: • Small populations ; Diverse economies and Cultures • Widely varying level of development • Intense movement via Trade, Labor and Tourism • Complex health situations • Most tourism dependent region in the world • Lack of communication, collaboration and information dissemination among different organizations • Deficiency in the regional and national information systems on surveillance, especially outbreaks and harmonization of food safety and quality standards

23. Challenges Faced In Implementing New Food Safety Strategies • Coordination, Communication, Turf and Ego issues: Getting people to work together • Between health, agriculture, policy (different ministries) • Between sectors: lab, epi, env, vet. • Between countries • Between agencies: regional and international • Recognition of Food safety as a priority & Health determinant • Absorptive capacity in countries • Varying/lack of in-country capacity: HR, Lab, Epi, $, Stds, SOPs • Tourism dependency: reliance on national and internat. surveill links • Many visitors present illness info upon return to their country • Hotels AFRAID to report ill visitors- bad publicity • Limited resources, competition for resources

24. Current & future food safety related activities CAREC’s Foodborne Diseases Prevention & Control programGoal: to strengthen national and regional capacity to develop and sustain effective integrated FBD surveillance and response programs • Initiated in 2002: Need for regional focus, coordination. • Integrated program : collating epidemiological, microbiological environmental and veterinary aspects of FBD and food safety • Farm to table, holistic, multidisciplinary coordinated approach • Interdepartmental, inter-country & interagency collaboration • Collaborative program: PAHO/CPC & INPPAZ • linking epidemiologist, microbiologists, environmental and veterinary officers • Networking of clinical, food, veterinary & analytical labs • links between Ministries of Agriculture and Health

25. Integrated surveillance Epidemiological Laboratory Environmental Environment Food Clinical (human) Veterinary (animal) Linking pathogens to the source: Farm to Table

26. Expected Results of Regional FBD program • Expand/Upgrade National & Regional Surveillance Systems for FBD • Improve FBD Outbreak Response, Investigation and Reporting • Strengthen Laboratory Infrastructure & Technical Capacity • Clinical, veterinary and food/analytical laboratories • Training and Human Resource Development • Research to support FBD • Provide Science-based Information • Promote Food safety standards for the Hospitality Industry • Coordination , Communication and Networking • Interdepartmental, bet. countries and bet. agencies with responsibility for food safety • more coordinated, integrated program for FBD surveillance and food safety  

27. Main Activities of FBD program: 2003-04 • Comprehensive joint FBD Program Plan [ with PAHO (HQ, CPC, INPPAZ)] for improving FBD surveillance in Caribbean • Familiarization with FBD program and establishment/ strengthening of partnerships with major stakeholders [local, regional, international] & CMCs • Country-specific draft inter-sectoral multidisciplinary protocols (in log frame format) for enhanced FBD surveillance and response in 14 CMCs • Assessment (via survey) of the epidemiological, laboratory, environmental and legislative capacity for FBD surveillance and response in 14 CMCs • Interagency integrated FBD surveillance workshop: 13 regional & internat. agencies and country multidisciplinary teams (nat. epidemiologist, laboratory director, chief environ. health & veterinary officers) from 14 CMCs; -to enhance integrated FBD surveillance, more coordinated interagency response. • Commitment from major regional and internat. agencies: more coordinated response to FBD surveillance, information sharing, and collaboration

28. Main Activities of FBD program: 2003-04 • Establishment of a FBD interdepartmental multidisciplinary team at CAREC • Implementation of phage typing, as a new laboratory reference service at CAREC, for improved surveillance and response esp outbreaks • Integrated Training (clinical, food, veterinary & env) • isolating Campylobacter & Salmonella, Serotyping and AMR • integrated FBD surveillance ,outbreak investigations; • Food safety (EHOs, hotel staff) • 22-year (1981-2004) and 13-year(1991-2004) Salmonella serotyping and AMR databases respectively for Salmonella isolates referred from CMCs • Development of integrated protocols for improved coordination of O.I • Establishment of Listservs for enhanced communication and coordination • linking lab. personnel: clinical, food, veterinary, analytical and university. • FBD teams (epidemiology, laboratory, environmental and vet) • QTC’s Food Safety and Sanitation Standards for Hospitality industry

29. Activities for 2005 • Revised FBD regional program plan - inputs from countries & agencies. • Protocol for regional interagency coordinating mechanism for FBD surveillance • Further strengthen collaborations with regional and international agencies • Refine national inter-sectoral FBD protocols into implementable format and establish in-country integrated FBD programs as part of overall surveillance • Collaborative regional Training workshops (PAHO, CDC, PHAC, WHO) • Global Salm-Serv III- multidisciplinary FBD training workshop (March 2005). • Burden of illness • Food safety and environmental standards (june 2005) • In country workshops • Lab. Training (isolation, serotyping, campylobacter) • Integrated FBD surveillance; food safety training and certification • Continue establishing protocols for coordinated multidisciplinary response to FBD outbreaks (in country, regionally with int. agencies) • Hotel based surveillance and reporting

30. Best practices in areas of food safety seen applied • Integrated FBD protocols- improve coordination and communication- improved trace back to source • Integrated outbreak surveillance and reporting (CORT) • Hotel based surveillance and linking to PH surveillance • Joint Research:- link academia to public health: e.g.SE study • Public- Private partnership to improve food safety : QTC • Multi-sectoral Education : Farmers, Consumers, Food Handlers • Food safety practices: Reduction of Egg pooling (SE outbreaks) • Egg Surveillance and Improvement in Farm Sanitation • Benefits of integrated surveillance: linking labs, epidemiologist, vet, EHOs: more timely surv and response, id of new and emerging problems, more effective use of ltd resources, increased communication , collaboration

31. How communication, harmonization & integration among food safety stakeholders across Canada be improved: CAREC view for effective trace-back of FBD involving Canadian visitors, trade • Integrated link between stakeholders from farm to table • between health and agriculture • surveillance, laboratory, policy, inspection, research training, • Seamless link between provinces, and hotel levels • Link between clinical, food and animal epidemiology and laboratories surveillance • One central/coordinated body to work with • Agency coordination