Following a significant outbreak of foodborne Shiga toxin-producing Escherichia coli (STEC) infections at childcare facilities across Calgary, Canada—the largest STEC outbreak associated with children in the Province of Alberta’s history—the Government of Alberta launched a review of the events, resulting in several recommendations that focus on fostering food safety culture and developing food safety inspection systems for these establishments and the kitchens that serve them.

The Largest STEC Outbreak Affecting Children in Alberta History

Alberta Health Services (AHS) was first made aware of the STEC outbreak in question on September 4, 2023. A total of 448 cases were associated with the outbreak, 359 of which were children; 38 children and one adult were hospitalized. The outbreak affected multiple childcare facilities in Calgary, and the source of illness was traced back to food prepared at one common kitchen.

The shared kitchen was issued a closure order on September 4, 2023, and public health inspectors were dispatched to the kitchen the next day. Several critical violations were found regarding food handling, sanitation, and pest control; another two noncritical violations were identified related to an odor and storage of utensils. Investigative and epidemiological data linked beef meatloaf and vegan loaf meals made in the shared kitchen and served to children on August 29, 2023 as the source of the outbreak.

Prior to the outbreak, the shared kitchen has been inspected by AHS four times between January and April 2023. During each of the four inspections, critical and noncritical violations were documented.

After reinspecting the shared kitchen in November 2023, AHS rescinded the closure order, as all violations were corrected. As part of the reopening agreement, the kitchen was allowed to operate in a limited capacity; specifically, without the ability to prepare full meals or transport food, but with the ability to receive and serve meals from an AHS-approved third-party contractor.

As of April 2024, AHS has identified 69 childcare centers in Alberta that access foods from a shared kitchen.

Review Panel Recommendations

In response to the outbreak, the Government of Alberta formed a Food Safety and Licensed Facility-Based Childcare Review Panel to assess the events and response surrounding the outbreak, with the goal of providing recommendations to strengthen food safety for Alberta’s children in licensed childcare facilities.

The review panel published 12 recommendations and 27 sub-recommendations across three themes: fostering a culture of food safety that supports healthy learning environments for children; strengthening public policy, legislation, and inspection systems for food safety; and systems alignment and integration. The 12 recommendations are as follows:

1. Promote and enable a food safety culture (FSC) in licensed childcare facilities and food establishments that service licensed childcare facilities: sub-recommendations include, but are not limited to, incorporating FSC requirements into legislation, developing indicators to measure FSC, and developing a grading system for inspections of licensed food establishments (to be displayed conspicuously on-premises).
2. Expand mandatory, evidence-based food safety education: specifically, by requiring food safety certification every three years and requiring an annual simplified food safety training course, both of which will include an FSC component.
3. Develop resources for operators of licensed food establishments and childcare facilities to make practicing FSC easier: for example, information sheets, templates for internal auditing, and checklists and logs.
4. Require licensed childcare providers to develop a policy on “outside food:” the policy should allow for flexibility across individual facilities.
5. Review and revise, as necessary, the Food Retail and Foodservices Code to ensure compliance with key food safety components: for example, maintaining records of sanitizer concentrations, end-point cooking temperatures, and cold storage temperatures of high-risk foods.
6. Develop clear and formalized expectations and measurable outcomes for AHS public health inspections: including risk assessment and categorization methodologies, increasing and monitoring inspection frequencies, and requiring rapid follow-up of outstanding violations in all licensed childcare facilities and kitchens serving those facilities.
7. Ensure Alberta has the capacity to more effectively respond to foodborne illness outbreaks and take immediate enforcement action on serious offenses and repeat violations by establishing public health investigators: this investigation team should be formally trained and distinct from, but collaborative with, existing public health inspectors. Sub-recommendations include, but are not limited to, amending the Public Health Act to define a path for pursuing violations to prosecution, setting standard operating procedures (SOPs) for AHS health inspectors and investigators, and ensuring AHS has a system to track and follow up with businesses that have a history of noncompliance.
8. Increase integration and alignment of Alberta Health food safety legislation to strengthen understanding of food safety and food handling requirements of childcare providers and regulators: this integration would affect several acts specific to different sectors.
9. Ensure that provincial crisis management/response plans and protocols for foodborne illness outbreaks are developed, roles and responsibilities are well-understood, and communication channels enhanced: sub-recommendations include, but are not limited to, allocating responsibility for outbreak response to a single entity, developing a response plan that defines which organizations execute different components of outbreak response and when, and developing an outbreak communication plan.
10. Establish procedures to facilitate prompt information-sharing between provincial governments during foodborne illness outbreaks: for example, through memoranda of understanding (MOUs), and amending the Alberta Foodborne Illness and Risk Investigation Protocol to outline how various Canadian member agencies will work together to conduct coordinated investigations.
11. Ensure that accredited laboratories are in place to assess foodborne illnesses and support health inspections/outbreak investigations: the laboratories should have the ability to analyze environmental swabs for foodborne pathogens, test foods for pathogens, and plan for surge capacity.
12. Support innovative research and models of care to leverage Alberta’s expertise in STEC infections and other foodborne pathogens to optimize acute and long-term clinical outcomes of infected children and to improve infrastructure to prevent and respond to future outbreaks: specifically, create STEC Center of Excellence designed to ensure that all STEC-infected children anywhere in the province receive state-of-the-art care as efficiently as possible.

The full, 104-page report, published by the Government of Alberta and including the complete list of recommendations, can be read here.