Consumers continue to demand convenient, healthy ready to eat foods such as sandwiches, previously cooked entrees and salads. While these foods offer convenience and nutrition, there are food safety concerns. Cook and serve foods have a limited preparation cycle, ending in a heat kill step. These convenience foods have multiple preparation steps (cleaning, preparation, cook, cool, portion, packaging, display) with as many chances for contamination. Often this involves employee food handling errors or a failure to clean and sanitize food contact surfaces. In these cases, the heat kill step occurs earlier in the preparation process, creating a potential for contamination in the final stages. Handling of these ready to eat foods is critical because any errors cannot be controlled through cooking.
Often the contamination centers on improper personal hygiene and the failure to restrict or exclude ill food service workers.. Two citations provide some evidence.
Pub Med Central Journal of Food Protection 2013 Nov;76(11):1824–1828. J. Hannah Gould, Ida Rosenblum, David Nicholas, Quyen Phan, Timothy F. Jones, “Contributing Factors in Restaurant-Associated Foodborne Disease Outbreaks, FoodNet Sites, 2006 and 2007”
In 257 of foodborne disease outbreaks documented in 2006 and 2007, (note: an outbreak involves multiple illnesses cases), nearly all (89%) of the outbreaks of norovirus infections and nearly half (15 outbreaks, 45%) of the outbreaks of Salmonella infections had contributing factors related to food worker health and hygiene. Contributing factors associated with food worker health and hygiene were reported for 165 (64%) of the 257 outbreaks for which a single causes was reported.
Moritz ED, Ebrahim-Zadeh SD, Wittry B, et al. Foodborne Illness Outbreaks at Retail Food Establishments — National Environmental Assessment Reporting System, 25 State and Local Health Departments, 2017–2019. MMWR Surveillance Summary 2023;72(No. SS-6):1–11.
During 2017–2019, a total of 800 foodborne illness outbreaks associated with 875 retail food establishments were reported. Among outbreaks with a confirmed or suspected agent (555 of 800 [69.4%]), the most common pathogens were norovirus and Salmonella, accounting for 47.0% and 18.6% of outbreaks, respectively. Contributing factors were identified in 62.5% of outbreaks. Approximately 40% of outbreaks with identified contributing factors had at least one reported factor associated with food contamination by an ill or infectious food worker.
In analyzing 555 foodborne disease outbreaks, the Centers for Disease Control (CDC) identified the top five contributing factors to foodborne illness outbreaks, as follows:
1. Other mode of contamination (excluding cross-contamination) by a food handler, worker, or preparer who was suspected to have an infectious illness; [104 cases, 20.8%]
2. Bare-hand contact of RTE food by a food handler, worker, or preparer who was suspected to have an infectious illness [72 cases, 14.4%]
3. Contaminated raw product (food was intended to be consumed raw, undercooked, or under processed) [88 cases, 17.6%]
4. Bare-hand contact with RTE food by a food worker who was suspected to have an infectious illness [72 cases 16.9%]
5. Gloved-hand contact of RTE food by a food handler, worker, or preparer who was suspected to have an infectious illness [53 cases, 10.6%]
6. Foods contaminated by nonfood handler, worker or prepared who was suspected to have an infectious illness [13 cases, 3.1%]
7. Cross contamination of ingredients [68 cases, 13.6%]
To summarize these findings, improper personal hygiene and employee illness were factors in 65.8% of the cases.
Why did this occur? Researchers surveyed 725 retail establishments. Of those interviewed, 91.7% had a policy requiring food workers to tell management when they are ill. 85.5% had a policy to restrict or exclude ill workers depending on the severity and type of illness. 62.4% had the policy in writing (this suggests the failure to use a written form) and 65.5% specified the symptoms which would require exclusion or restriction from work. A missing question was whether or not employees received training about this policy; this is a legal requirement. While the survey results may appear impressive, consider that these surveys are voluntary and the results are likely biased.
This research suggests that foodborne illness outbreaks continue, over a long time period, to be influenced by improper personal hygiene and employee illness. The managers in this survey, at least, appear uninformed about the legal requirements for restricting or excluding ill employees.
The United States Food and Drug Administration (FDA) Recommended Food Service Code (commonly adopted by nearly all public health agencies) contains requirements for employee personal hygiene and the reporting of employee illness.
2-102.11 (paraphrase) Food service persons in charge are required to … Explain(ing) how the person in charge, food employees, and conditional employees comply with reporting responsibilities and exclusion or restriction of food employees.
Further in 2-201.11 The permit holder shall require food employees….to report …information about their health …as they relate to disease that are transmissible through food.
The Code goes on to specify that employees must report to management if they have…. (a) reportable symptoms; (b) reportable diagnosis; (c) reportable past illness; (d) reportable history of exposure; (e) responsibility of the person in charge to report to the regulatory authority; and (f) responsibility of the person in charge to exclude or restrict affected employees.
Note: The FDA 2022 Code has two provisions relating to these requirements which might be new to some readers.
First, regarding the provision on ‘reportable past illness’, reporting is required for employees who
had typhoid fever, diagnosed by a health practitioner, within the past three (3) months, without having received antibiotic therapy, as determined by a health practitioner.
Second, regarding the provision on ‘reportable history of exposure’, reporting is required for employees who (have)
been exposed by attending or working in a setting where there is a confirmed disease outbreak or living in the same household as…where there is a confirmed disease outbreak …caused by Norovirus within the past 48 hours of the last exposure; Shiga toxin producing Escherichia Coli or Shigella within the past 3 days of the last exposure; Typhoid fever within the past 14 days of the last exposure; and Hepatitis A virus within the past 30 days of the last exposure.
While these blog postings are often critical, the attempt is always to provide resources and information. The FDA has posted two resources which might help managers to comply with these requirements.
https://www.fda.gov/media/179698/download?attachment Employee Health Policy Tool – To quote from the document forward, ‘this tool will help users navigate restriction and exclusion requirements identified in 2-201.11 of the 2022 FDA Food Code using clickable pathways dependent upon the role of the user and the symptoms and/or diagnoses presented’.
https://www.fda.gov/media/77065/download?attachment Employee Health and Personal Hygiene Handbook This handbook contains the forms your sanitarian often asks for during inspections. To quote the document forward, ‘this handbook also provides easy reference to forms and tables that retail food establishments and the public health community may find useful when training staff and addressing employee health and hygiene matters. The information in this handbook has been updated to reflect the most current full edition of the 2017 FDA Food Code and includes the following new additions’