It affects 1 in 6 Americans annually, according to Centers for Disease Control and Prevention (CDC) data published in 2011. You may also know that at least two out of three FBI outbreaks trace back to food prepared outside the home—as in a restaurant, an institution, or a retail establishment.
Why? We can talk about causes, and you can probably name culprits straight out of media headlines: E. coli, Salmonella, Clostridium, Listeria, Norwalk virus, and many other pathogens. These pathogens are everywhere, yet not every meal leads to illness (thankfully). In analyzing FBI outbreaks, the CDC identifies contributing factors. These are not the pathogens. Rather, they are the factors that allow pathogens to thrive and persist through the flow of food, ultimately causing an outbreak.
According to the CDC, the top five contributing factors to FBI in foodservice and retail food establishments are:
During the past 10 years, the FDA has been conducting on-site research regarding compliance with specific FDA Food Code guidance related to these five factors. In its 2009 report, Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurant, and Retail Food Store Facility Types, FDA analysts cited personal hygiene, time and temperature control, and protection from contamination (#2, #4, and #5) as “areas most in need of improvement.”
They noted, “Foodservice and retail food store operators must ensure that their management systems are designed to achieve active managerial control over the risk factors.” In this short CE program, you will learn more about contributing factor #5.
Sources: Centers for Disease Control & Prevention (CDC). 2011 Estimates of Foodborne Illness in the United States.
Food and Drug Administration (FDA). FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurant, and Retail Food Store Facility Types (2009)
The word “cross” sometimes confuses people. Why “cross”? It’s the idea that something dangerous crosses from any item to food. For example, when your hands are unclean and you touch a slice of bread, bacteria cross from your hands over to the bread.
In food safety, most people use “cross contamination” to describe pathogens passing to a food. Technically, contamination can be anything that makes the food unsafe—even a cleanser or a food allergen.
Consider the flow of food. As each food ingredient and recipe moves through the process defined in your organization, it has multiple opportunities to become contaminated. The job of a foodservice manager is to anticipate and control each of these opportunities, or “risks”. A typical flow of food begins with food being received and checked in, then transferred to storage. Later, it may be retrieved from storage and used in a recipe. Later still, the food may undergo transportation and/or holding in a service area. Finally, it may be stored again for future use.
Even a home kitchen has a flow of food. Someone brings home groceries, places them in storage, and uses foods to make meals.
While a food is following its flow in any kitchen, contamination can occur at any point. (Remember, it can even enter your doors contaminated.) Once contamination occurs, pathogens in food pose a food safety risk.
One of today’s most respected food safety models, the Hazard Analysis and Critical Control Point (HACCP) system, targets controls where risks are highest and interventions can have the greatest impact. For example, foods that risk being contaminated undergo cooking to defined time and temperature standards. This mitigates the food safety risk.
However, other foods are ready-to-eat. This means they will undergo no cooking (or further cooking). An example is a sliced turkey and avocado deli sandwich. If it becomes contaminated with Staphylococcus bacteria from a foodservice worker’s skin, the bacteria are likely to live on. Upon cross contamination, odds of causing an illness are higher when the food involved is ready-to-eat. Typically, there are no further controls to mitigate this hazard.
There are two typical ways that cross contamination occurs:
Let’s look more closely. First, Pathogens cross from one food to another food. Here are some examples:
Now we’ll look more closely at the second kind of cross contamination:
Pathogens pass from food-contact surfaces of equipment or utensils to food. Here are some examples:
Cutting boards are often a focus of equipment contamination, simply because they are used so extensively in pre-preparation procedures. This is why some managers choose color-coded cutting boards. At a minimum, if a cutting board is reserved for meat or for fresh produce, the risk is reduced. However, all food contact surfaces are at play. This includes cutting boards, knives, countertops, blenders, mixers, utensils, storage containers, serving pans, and even potholders and aprons. Needless to say, proper cleaning and sanitizing between processes are the key weapon against this kind of cross contamination.
It’s important to focus on entire work areas, not just a bowl or a utensil. British researchers demonstrated that simple food preparation tasks like cracking an egg can contaminate work surfaces as far away as 40 cm (about 16 inches) with Salmonella. When eggs are mixed or whisked as part of a recipe, they said, “contamination of surfaces around the mixing bowl was a common occurrence.” They also noted, “Once present on formica work surfaces, S. enteritidis survived well.” Bacteria were still present after 24 hours.
Source: Cambridge University Press. Contamination of hands and work surfaces with Salmonella enteritidis PT4 during the preparation of egg dishes
The facts are alarming. The FDA study on FBI risk factors indicates that “proper, adequate handwashing” was the food safety control most “out of compliance” with FDA Food Code standards. Only 36% of the the items that related to handwashing passed the audit. Among retail meat departments, the number dipped to 18%.
According to the FDA, “Handwashing reduces the spread of pathogenic microorganisms that are transmitted through food. The hands of food employees can be colonized with microorganisms such as Staphylococcus aureus or contaminated with organisms from human fecal material, such as Norovirus, Shigella spp., hepatitis A virus,E. coli O157:H7, or Salmonella Typhi, or contaminated from raw animal foods, with E. coli O157:H7 and Salmonella spp. These and other pathogenic microorganisms can get on the hands from a number of sources and then move from hands to food during preparation and service.
“An infected food employee and/or food employees with unclean hands, and exposed portions of arms or fingernails, can contaminate food. If a consumer eats contaminated food, foodborne illness may result.”
While reasons, triggers, and procedures for handwashing are well known, compliance is an ongoing concern in both foodservice and healthcare industries. As reported in Cracking Edge newsletter, compliance with handwashing protocols in hospitals stands at less than 50 percent. Typical handwashing messages tell healthcare workers to wash their hands to avoid illness. But many healthcare workers are better motivated by messages that focus on patients, according to recent research, They suggest that routinely refreshing messages may improve compliance, too. Example: “Did you wash your hands? What if your mother was the next patient you saw?”
Sources: Food and Drug Administration (FDA). FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurant, and Retail Food Store Facility Types (2009)
Safest Choice™. Cracking Edge Newsletter Sep. 2011
Using the targeted contributing factors and Food Code standards as a guide, researchers actually inspected 850 foodservice operations around the nation and directly measured compliance with best practices. They included a range of foodservice segments—hospitals, nursing homes, elementary schools, fast food restaurants, full service restaurants, and departments of retail food stores.
The study was designed to:
Researchers concluded, “Improper cleaning and sanitizing of food-contact surfaces before use was the item most commonly observed to be Out of Compliance in eight out of the nine facility types. Percent Out of Compliance values for this data item ranged from 18% in seafood departments to 64% in full service restaurants.” Take a look at the FDA summary graphs below to see details for hospitals, nursing homes, fast food, and full-service restaurants. For more details on finding by foodservice segment, see the complete FDA report online.
The FDA researchers used five audit points derived from the FDA Food Code. These are targeted takeaway points for foodservice operators as well.
Source: Food and Drug Administration (FDA). FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurant, and Retail Food Store Facility Types(2009)
According to Colin Caywood, writing in Food Safety News, the self-service model of buffet dining “practically invites… cross contamination issues.” This is because patrons are now practicing food service, but without the requisite training in foodservice sanitation.
Caywood cites examples of FBI outbreaks that traced back to buffet dining. One involved E. coli bacteria in Minnesota, linked to a Chinese buffet. Victims suffered severe infection and had to be hospitalized.
Another involved Salmonella Heidelberg at a buffet restaurant in North Carolina. Not one, but three meat entrees tested positive for the bacteria. Two employees were infected as well. Researchers could not determine whether the employees were sources or victims of a pathogen spread through the buffet.
Yet another case Caywood cites involved the breakfast buffet of a hotel in Colorado. Multiple groups of guests (and staff) became ill with Shigellosis.
Caywood emphasizes controlling risk factors such as temperature control and protecting food from contamination.
Source: Caywood, C. Buffets and Cross-contamination, Food Safety News, July 20, 2010
As reported by the University, “Chapman’s study found approximately one cross-contamination event per food handler per hour. In other words, the average kitchen worker committed eight cross-contamination errors, which have the potential to lead to illnesses, in the course of the typical eight-hour shift.”
Chapman also found that the rate of error in personal hygiene and cross contamination increased dramatically during peak meal times.
"The prevalence of cross contamination is a hidden problem for food service, as food handlers acting in a multi-user environment may not see themselves as part of a team. Many of the recorded indirect cross contamination events occurred when multiple food handlers used common food contact surfaces, utensils, or equipment.”
Chapman and colleagues have been testing interventions for improving food-safe practices.
Source: Chapman, B. Video Study Finds Risky Food-Safety Behavior More Common Than thought, NC State University Newsroom, June 08, 2010
It’s estimated that 12 million Americans (4% of the population) have one or more food allergies, which are responsible for 30,000 emergency room visits and 150 deaths in the US each year.
Accordingly, the 2009 edition of the FDA Food Code rolled out new guidance regarding food allergies. The “person in charge” at a foodservice establishment is now accountable for being able to identify common food allergens and recognize symptoms of an allergic response to food. Common food allergens, those most frequently involved in serious allergic reactions, are: milk, eggs, fish (e.g. bass, flounder, cod), shellfish (e.g. crab, lobster, shrimp), tree nuts (e.g. almonds, walnuts, pecans), peanuts, wheat, and soybeans.
For individuals who are highly susceptible to allergic reactions, cross contamination is a critical issue. Controls extend beyond simply choosing (or avoiding) foods on a menu. Cross contamination of foods and/or work surfaces with allergens from other foods can trigger a life-or-death response. Says the FDA in its Food Code Annex, “The person in charge establishes an important barrier to food contamination.”
The Wisconsin Department of Public Instruction provides these guidelines for preventing cross contamination with food allergens:
During Food Preparation:
Meal Service and Clean up:
Sources: The Wisconsin Department of Public Instruction. Preparation of Foods with Potential to Cause Allergic Reaction Standard Operating Procedure.
Food and Drug Administration (FDA).
Food Code 2009 Food and Drug Administration (FDA). FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurant, and Retail Food Store Facility Types(2009)
To prevent food-to-food cross contamination:
To prevent equipment and food contact surface-to-food cross contamination:
To prevent chemical contamination:
Source: National Food Service Management Institute. Food Safety Fact Sheet, Preventing Cross Contamination During Food Storage (2009).
It takes more time to thoroughly sanitize work surfaces and equipment adequately than it does to use one item to wipe down everything. It is up to the foodservice manager to practice what the FDA Food Code calls “active managerial control” to implement practices, train team members, monitor compliance, and coach employees in actions that protect customers from FBI.
The National Food Service Management Institute offers these additional tips for preventing cross contamination during preparation.
Source: National Food Service Management Institute. Food Safety Fact Sheet, Preventing Contamination During Food Preparation (2009).
Consumer education can include messages that closely parallel those of foodservice. The USDA, in its fact sheet, “Be Smart. Keep Food Apart,” offers tips for consumers that address all steps in the flow of food.
David L. Williams and colleagues, reporting in Food Protection Trends, determined that a growing consumer trend—reusable grocery bags—presents a cross contamination risk. The researchers found that about half of bags were contaminated with coliform bacteria. Coliform bacteria, a general category identifying bacteria that are common in feces, are used as a marker of biological contamination. E. coli is one example of a coliform bacteria, and in fact, 8% of the bags were contaminated with E. coli.
Researchers also noted, “When meat juices were added to bags and stored in the trunks of cars for two hours, the number of bacteria increased 10-fold.” Fortunately, there is a simple solution: washing the bags on a regular basis. They recommend public educational efforts around this message.
NSF identifies the 10 “germiest” places in the home as documented by household swabs and cultures in 2011. Clearly, many relate to food handling in the home kitchen.
One microbiology expert, Charles Gerba, PhD of the University of Arizona, was quoted by Philly.com as saying, ``You'd be better off eating a carrot stick that fell in your toilet than one that fell in your sink.'' He has also pointed out that cutting boards used for raw meat can carry 200 times more bacteria than a toilet seat. (Consumer Reports, March 2012).
Note that 30% of homes reviewed by NSF tested positive for coliform contamination on the countertops. NSF said that this can come from a variety of foods passing through the food preparation process in a home kitchen, as well as pet toys and bowls. Consumer advice offered by NSF includes:
Sources: United States Department of Agriculture, Food Safety and Inspection Service. Be Smart. Keep Foods Apart. Don't Cross-Contaminate., December 15, 2010
Williams, David L. et al. Assessment of the Potential for Cross-contamination of Food Products by Reusable Shopping Bags. Food Protection Trends, vol. 31, no. 8, 2011.
NSF International, Top Ten Germiest Places in the Home
We invite you to explore the food safety resources listed on slide 17 to learn more about food safety.
If you would like to submit your evaluation and comments to the Commission on Dietetic Registration, you may do so at http://www.cdrnet.org.
Chapman, Benjamin, et al. Assessment of food safety practices of food service handlers (risk assessment data): testing a communication intervention (evaluation of tools). Journal of Food Protection, vol. 73, no. 6, 2011.
FDA. Food Allergens
Humphrey, T.J., et al. Contamination of hands and work surfaces with Salmonella enteritidis PT4 during the preparation of egg dishes. Epidemiol. Infect. Vol. 113, 1994.
Minnesota Department of Health. Five Common Ways Germs are Spread (free PDF poster)
National Pasteurized Eggs. Food Safety—It’s in Your Hands (food safety inservice training materials)
National Restaurant Association. About Foodborne Illness: Common Pathogens.
USDA. Food Safety Fact Sheets
Washington State University et al. You Can Prevent Foodborne Illness (free PDF brochure)
Williams, David L. et al. Assessment of the Potential for Cross-contamination of Food Products by Reusable Shopping Bags. Food Protection Trends, vol. 31, no. 8, 2011.
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Debbie Rayhab. MBA, Healthcare Marketing Manager
National Pasteurized Eggs, Inc.