Potential Human Health Effects of Foodborne Infections from Improper Food Handling

1. Escherichia coli Potential Human Health Effects of Foodborne Infections from Improper Food Handling Winnie Chan

2. Learn how to prevent food-borne infections at home, at restaurants, and at market places. • Learn about policies regulating safe food handling, including preparation of fresh produce • Understand the implications of improper food handling for public health professionals, and what actions can be done

3. Importance of the Problem •  Every year, 1 out of 6 people in the United States—48 million people--suffers from foodborne illness, more than a hundred thousand are hospitalized, and thousands die.  • Food-borne infections linked with improper handling of contaminated food can happen anywhere that deals with animal products or fresh produce • Growing concern re. food safety in restaurants and at markets, since more individuals dine out on a daily basis.

4. Importance of the Problem, cont’d • From 2009-2010, among the outbreaks with a known single setting where food was consumed, • 48% were caused by food consumed in a restaurant or a deli & • 21% were caused by food consumed in private home. • Of the 29,444 outbreak-related illnesses, 1,184 (4%) resulted in hospitalization: • Salmonella caused the most outbreak-related hospitalizations (49%), followed by Shiga toxin-producing E. coli(16%), and norovirus (9%).

5. Food-Borne Infections Linked with Improper Food Handling • Norovirus: • Stomach bug • Often spread through unwashed hands

6. Link: Infected Food Handlers • If exposed to an infected employee, diners and the employee colleagues’ are susceptible to an infection, esp. if food was prepared without gloves. • Regardless of facilities passing health inspections the prior week without violations, Salmonella can still spread from the infected employee who worked that day (Hedberg et al. 2013, pp.1139-1140). • If food was prepared with gloves, surfaces were cleaned repeatedly, and food handlers frequently washed their hands, then the likelihood of contamination would decrease.

7. Link: Poor Personal Hygiene • Poor personal hygiene of food workers, such as failure to wear hair nets and wearing dirty work clothes, is the 2nd most frequently cited contributory factor in food-borne illness outbreaks (Todd et al. 2010, p. 1763). • Pathogens like E. coli may remain outside the glove after long periods, showing that gloves do not completely prevent pathogen transfer (Todd et al. 2010, p. 1766). • While gloves are an important barrier against food contamination, food handlers must also wash hands and wear appropriate clothing to reduce risk of the spread of food-borne disease.

8. Link: Proper Hand Washing Behavior • Low compliance with proper hand washing behavior in four sectors of the retail service industry studied: assisted living facility, childcare, restaurants, schools • Thus, 250 to 350 million people in the United States have experienced gastroenteritis, with 25-30% of cases caused by food-borne illnesses (Strohbehn et al. 2008, p. 1641). • It is particularly critical when employees are serving food to vulnerable individuals, such as young children and the elderly (Strohbehn et al. 2008, 1641).

9. Link: Contaminated Fresh Produce • In USA, the desire for year-round fresh produce means that during colder weather, produce will likely be transported from farther away (Lynch et al. 2008, p. 308). • Unfortunately, Salmonella and other enteric bacterial pathogens can survive transportation or storage for long periods, allowing likelihood of contamination and outbreaks.

10. Link: Cross Contamination • After preparing a contaminated produce item,, knife cross-contamination easily occurs after improper post-production food handling (Wang et al. 2012, pp. 53). • The use of clean utensils after cutting a contaminated fruit increases the accumulation of virus residue on the surface, which spreads if it is repeatedly used without being cleaned (Wang et al. 2012, p. 54). • Workers must also repeatedly wash kitchen utensils, as they easily become a mode of transmission.

11. Summary • Many ways of contamination! • Infected food handlers who don’t wear gloves • Lack proper hand-washing behavior • Rise of contaminated fresh produce • Cross contamination by utensils

12. Food Safety Policies & Regulations • Local • Retail Food Safety Program (SF) • State • CA Food Handler Card, SB 602 • CA Retail Food Code, an excerpt from California Health and Safety Code, effective Jan 1, 2012 • Animal Health and Food Safety Services (AHFSS ) of the CA Dept. of Food and Agriculture • Animal Health Branch; Bureau of Livestock Identification; • Meat, Poultry and Egg Safety Branch; Milk and Dairy Food Safety Branch • Food Safety Program of the Food & Drug Branch • Requires Food Safety Certification • Federal • FDA Food Safety Modernization Act (FSMA) • USDA’s Food Safety and Inspection Service (FSIS) launched the “Hold and Test” E. coli control policy in Dec. 2012 • USDA launched the Public Health Information System • USDA promotes a “Be Food Safe” campaign to avoid food contamination

13. Local Policies • In San Francisco, the Retail Food Safety Program monitors compliance of local and state food safety regulations in restaurants, markets, and all other retail food operations. • Provides permits • Ensure compliance of health codes • Inspect/monitor all retail food operations • Enforce policies!

14. State Policies • CA Food Handler Card • SB 602: Requires workers to receive food safety training to reduce potential for foodborne illnesses within 30 days from the date of hire • Valid for 3 years; Minimum score of 70%; ~$15/training; LHD • California Retail Food Code • Provides regulation for food facilities to have proper safe food handling. • Enforced by 62 local env. health regulatory agencies

15. State Policies, Cont’d • Animal Health and Food Safety Services (AHFSS) of the CA Dept. of Food and Agriculture • Mission: Assure the safety, availability, and affordability of agricultural products while protecting public and animal health. • Food Safety Program of the Food & Drug Branch • Mission: protect and improve the health of consumers by assuring foods are safe, and are not adulterated, misbranded, or falsely advertised.

16. Federal Policies • FDA’s Food Safety Modernization Act (FSMA) • Jan. 4, 2011. Enables FDA to focus more on preventing food safety problems rather than reacting to problems after they occur. • For the first, FDA has legislative power to mandate prevention-based controls re. food supply! • USDA’s Food Safety and Inspection Service (FSIS) launched the “Hold and Test” E. coli control policy • Meat products must test negative for Shiga-toxin producing E. coli • USDA promotes a “Be Food Safe” campaign to avoid food contamination: • Clean, Separate, Cook, and Chill

17. Implication for Public Health Professionals • With the growing knowledge of produce-related outbreaks, we must enforce proper food handling to prevent contamination during the processing, distribution, and service stages! • Exposure to even a small amount of Salmonella can cause an outbreak, so preventing it, along with other infections, at the earliest stages is essential (Hedberg 2013, p. 1135). • Young children and elderly are most vulnerable: must protect them!

18. References • CDC (2013). Tracking and reporting foodborne disease outbreaks. Retrieved from http://www.cdc.gov/features/dsfoodborneoutbreaks/. • Hedberg, C., White, K., Johnson, J., Edmonson, L…., & Osterholm, M. (1991). An outbreak of salmonella enteritidis infection at a fast-food restaurant: implications for food handler-associated transmission. Journal of Infectious Diseases, 164(6), 1135-1140. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1955712 • Lynch, M., Tauxe, R., & Hedberg, C. (2009). The growing burden of foodbourne outbreaks due to contaminated fresh produce: risks and opportunities. Epidemiology and Infection, 137 (3), 307-315. doi:10.1017/S0950268808001969

19. References, Cont’d • Strohbehn C., Sneed J., Paez P.,& Meyer J. (2008). Hand washing frequencies and procedures used in retail food services. Journal of Food Protection, 71(8):1641-50. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18724759 • Todd, E., Michaels, B., Greig, J., Smith, D., & Bartleson, C. (2010). Outbreaks where food workers have been implicated in the spread of foodborne disease. Journal of Food Protection, 73 (9), 1762-1773. Retrieved from http://0search.ebscohost.com.ignacio.usfca.edu/login.aspx?direct=true&db=cmedm&AN =20828485&site=eds-live&scope=site • Wang, Q., Erickson, M., Ortega, Y., & Cannon, J. (2013). The fate of murinenorovirus and hepatitis A virus during preparation of fresh produce by cutting and grating. Food Environmental Virology, 5(1), 52-60.  doi: 10.1007/s12560-012-9099-4.