title: Challenges in listeriosis cluster and outbreak investigations, Province of Quebec, 1997-2011.
abstract: OBJECTIVE
  Public health authorities place a high priority on investigating listeriosis outbreaks, and these epidemiological investigations remain challenging. Some approaches have been described in the literature to address these challenges. This review of listeriosis clusters and outbreaks investigated in the Province of Quebec (Quebec) highlights investigative approaches that contributed to identifying the source of these outbreaks.
  
  
  METHODS
  The Laboratoire de Santé Publique du Québec (LSPQ) implemented pulsed-field gel electrophoresis (PFGE) molecular subtyping in 1997 to identify Listeria monocytogenes clusters among isolates from invasive listeriosis cases identified throughout Quebec. A cluster was defined as three cases or more with the same or similar PFGE profiles (≤3 band difference) occurring over a 4-month period. An investigation was initiated if the epidemiologic indicators suggested a common source. Listeriosis data from LSPQ's database were reviewed to identify and describe clusters detected from 1997 to 2011, including those that led to an outbreak investigation. Epidemiological reports prepared following each outbreak were also reviewed.
  
  
  RESULTS
  Eleven clusters were identified in the province by LSPQ between 1997 and 2011. Outbreak investigations were initiated for six clusters, four of which involved more than 10 cases. Factors that contributed to identifying the source for three of these outbreaks highlighted the value of (1) making all stakeholders (food safety and inspection services, public health authorities, and laboratories) aware of any ongoing investigation and sharing relevant information even if the source is not yet identified; (2) promptly collecting food samples identified and considered as possible vehicles of infection identified during the interview of a Listeria case; (3) collecting food items and/or environmental samples in locations reported in common by cases in the same cluster.
  
  
  CONCLUSIONS
  Multiple approaches should be considered when investigating L. monocytogenes clusters. Networks to facilitate continuous exchange of human and food data between public health and food safety partners should be encouraged.
authors.affiliation: 1 Ministère de la Santé et des Services Sociaux , Québec, Québec, Canada .
authors.forename: Colette
authors.initials: C
authors.lastname: Gaulin
authors.forename: Geneviève
authors.initials: G
authors.lastname: Gravel
authors.forename: Sadjia
authors.initials: S
authors.lastname: Bekal
authors.forename: Andrea
authors.initials: A
authors.lastname: Currie
authors.forename: Danielle
authors.initials: D
authors.lastname: Ramsay
authors.forename: Sophie
authors.initials: S
authors.lastname: Roy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D004196:Disease Outbreaks; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D005506:Food Contamination / Q000032:analysis*; D005516:Food Microbiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008089:Listeria monocytogenes / Q000302:isolation & purification; D008088:Listeriosis / Q000453:epidemiology*; D008875:Middle Aged; D011247:Pregnancy; D011634:Public Health; D011792:Quebec / Q000453:epidemiology; D055815:Young Adult