Quantitative Risk Assessment of Norovirus Transmission in Food Establishments: Evaluating the Impact of Intervention Strategies and Food Employee Behavior on the Risk Associated with Norovirus in Foods

Usefulness and Limitations of PFGE Diagnosis and Nucleotide Sequencing Method in the Analysis of Food Poisoning Pathogens Found in Cooking Employees

In the case of a food poisoning outbreak, it is essential to understand the relationship between cooking workers and food poisoning. Many biological diagnostic methods have recently been developed to detect food poisoning pathogens. Among these diagnostic tools, this study presents PCR-based pulsed-field gel electrophoresis and nucleotide sequencing diagnostic analysis results for diagnosing food poisoning outbreaks associated with cooking employees in Chungcheongnam-do, Republic of Korea. Pulsed-field gel electrophoresis was useful in identifying the food poisoning outbreaks caused by Staphylococcus aureus and Enteropathogenic Escherichia coli. In the case of Norovirus, nucleotide sequencing was used to identify the relationship between cooking workers and the food poisoning outbreak. However, it is difficult to determine whether cooking employees directly caused the food poisoning outbreaks based on these molecular biological diagnostic results alone. A system is needed to integrate epidemiological and diagnostic information to identify a direct correlation between the food poisoning outbreak and cooking employees.

An agent-based model to simulate SARS-CoV-2 contamination of surfaces and meat cuts in processing plants

At the beginning of the COVID-19 pandemic, several contamination clusters were reported in food-processing plants in France and several countries worldwide. Therefore, a need arose to better understand viral transmission in such occupational environments from multiple perspectives: the protection of workers in hotspots of viral circulation; the prevention of supply disruption due to the closure of plants; and the prevention of cluster expansion due to exports of food products contaminated by the virus to other locations. This paper outlines a simulation-based approach (using agent-based models) to study the effects of measures taken to prevent the contamination of workers, surfaces, and food products. The model includes user-defined parameters to integrate characteristics relating to SARS-CoV-2 (variant of concern to be considered, symptom onset…), food-processing plants (dimensions, ventilation…), and other sociodemographic transmission factors based on laboratory experiments as well as industrial and epidemiological investigations. Simulations were performed for a typical meat-processing plant in different scenarios for illustration purposes. The results suggested that increasing the mask-wearing ratio led to great reductions in the probability of observing clusters of more than 25 infections. In the case of clusters, masks being worn by all workers limited the presence of contamination (defined as levels of at least 5 log10 viral RNA copies) on meat cuts at less than 0.05 % and maintained the production capacity of the plant at optimal levels. Increasing the average distance between two workers from less than 1 m to more than 2 m decreased the cluster-occurrence probability by up to 15 % as well as contamination of food products during cluster situations. The developed approach can open up several perspectives in terms of potential communication-support tools for the agri-food sector and further reuses or adaptations for other hazards and occupational environments.

Evaluation of the Impact of Compliance with Mitigation Strategies and Frequency of Restaurant Surface Cleaning and Sanitizing on Control of Norovirus Transmission from Ill Food Employees Using an Existing Quantitative Risk Assessment Model

ABSTRACT

Reduction of foodborne illness caused by norovirus (NoV) continues to be a focus for the food safety community. Using a previously published quantitative risk assessment model, we evaluated more than 60 scenarios examining the impact of implementation of and compliance with risk management strategies identified in the U.S. Food and Drug Administration Food Code for (a) surface cleaning and sanitizing, (b) hand hygiene, (c) exclusion, or (d) restriction of ill employees. Implementation of and compliance with hand hygiene and ill food employee exclusion strategies had the largest impact on the predicted number of highly contaminated food servings and associated consumer illnesses. In scenarios in which gloves were always worn and hand washing compliance was 90%, the model estimated reductions in the number of highly contaminated food servings and ill consumers to 39 and 43% of baseline estimates (i.e., typical practice), respectively. Reductions were smaller when gloves were never worn. Hand washing compliance after using the restroom strongly impacted predicted numbers of highly contaminated servings and consumer illnesses. Ten percent compliance with removing or excluding ill food employees was predicted to increase the number of highly contaminated food servings and ill consumers to 221 and 213% of baseline estimates, respectively. Ninety-four percent compliance with exclusion of ill food employees was predicted to decrease these numbers to 69 and 71% of baseline estimates, respectively. Surface cleaning in food establishments had a relatively small impact on these measures. Restriction of food employees (removed from contact with food and food contact equipment and utensils) was not effective for reducing NoV illness unless this restriction included additional provisions. The results from this study can help risk managers prioritize mitigation strategies and their implementation for controlling the transmission of NoV and subsequent consumer foodborne illness.

HIGHLIGHTS

Assessment of Food and Waterborne Viral Outbreaks by Using Field Epidemiologic, Modern Laboratory and Statistical Methods-Lessons Learnt from Seven Major Norovirus Outbreaks in Finland

Seven major food- and waterborne norovirus outbreaks in Western Finland during 2014–2018 were re-analysed. The aim was to assess the effectiveness of outbreak investigation tools and evaluate the Kaplan criteria. We summarised epidemiological and microbiological findings from seven outbreaks. To evaluate the Kaplan criteria, a one-stage meta-analysis of data from seven cohort studies was performed. The case was defined as a person attending an implicated function with diarrhoea, vomiting or two other symptoms. Altogether, 22% (386/1794) of persons met the case definition. Overall adjusted, 73% of norovirus patients were vomiting, the mean incubation period was 44 h (4 h to 4 days) and the median duration of illness was 46 h. As vomiting was a more common symptom in children (96%, 143/149) and diarrhoea among the elderly (92%, 24/26), symptom and age presentation should drive hypothesis formulation. The Kaplan criteria were useful in initial outbreak assessments prior to faecal results. Rapid food control inspections enabled evidence-based, public-health-driven risk assessments. This led to probability-based vehicle identification and aided in resolving the outbreak event mechanism rather than implementing potentially ineffective, large-scale public health actions such as the withdrawal of extensive food lots. Asymptomatic food handlers should be ideally withdrawn from high-risk work for five days instead of the current two days. Food and environmental samples often remain negative with norovirus, highlighting the importance of research collaborations. Electronic questionnaire and open-source novel statistical programmes provided time and resource savings. The public health approach proved useful within the environmental health area with shoe leather field epidemiology, combined with statistical analysis and mathematical reasoning.

Norovirus transmission mitigation strategies during simulated produce harvest and packing

In the agricultural setting, core global food safety elements, such as hand hygiene and worker furlough, should reduce the risk of norovirus contamination on fresh produce. However, the effect of these practices has not been characterized. Using a quantitative microbial risk model, we evaluated the individual and combined effect of farm-based hand hygiene and worker furlough practices on the maximum risk of norovirus infection from three produce commodities (open leaf lettuce, vine tomatoes, and raspberries). Specifically, we tested two scenarios where a harvester's and packer's norovirus infection status was: 1) assumed positive; or 2) assigned based on community norovirus prevalence estimates. In the first scenario with a norovirus-positive harvester and packer, none of the individual interventions modeled reduced produce contamination to below the norovirus infectious dose. However, combined interventions, particularly high handwashing compliance (100%) and efficacy (6 log10 virus removal achieved using soap and water for 30 s), reduced produce contamination to <1-82 residual virus. Translating produce contamination to maximum consumer infection risk, 100% handwashing with a 5 log10 virus removal was necessary to achieve an infection risk below the threshold of 0.032 infections per consumption event. When community-based norovirus prevalence estimates were applied to the harvester and packer, the single interventions of 100% handwashing with 3 log10 virus removal (average 0.02 infection risk per consumption event) or furlough of the packer (average 0.03 infection risk per consumption event) reduced maximum infection risk to below the 0.032 threshold for all commodities. Bundled interventions (worker furlough, 100% glove compliance, and 100% handwashing with 1-log10 virus reduction) resulted in a maximum risk of 0.02 per consumption event across all commodities. These results advance the evidence-base for global produce safety standards as effective norovirus contamination and risk mitigation strategies.

Quantitative microbial risk assessment of human norovirus infection in environmental service workers due to healthcare-associated fomites

BACKGROUND

Healthcare-associated norovirus outbreaks place a large burden on healthcare staff. Environmental service workers (ESWs), however, remain understudied despite high contact with potentially contaminated surfaces. Understanding the magnitude of the risk of norovirus infection in healthcare ESWs can protect workers and improve infection control.

AIM

This study simulated the risk of norovirus infection for unprotected ESWs after a single fomite contact, assuming no disinfection or protective equipment, in norovirus-positive patient rooms. In addition, the risk of secondary surface transmission from norovirus-exposed ESWs was simulated.

METHODS

A quantitative microbial risk assessment employing two-dimensional Monte Carlo simulation with parameters extracted from the literature was used to estimate norovirus infection from multiple fomite contact scenarios defined by: norovirus source (patient vomit/diarrhoea), location (bathroom/patient room) and target outcome (ESW/secondary illness).

FINDINGS

Unprotected ESWs have a maximum estimated risk of norovirus infection of 33% (1:3) for a single fomite contact in a room where a norovirus-positive patient had a diarrhoeal event. Patient vomit events lead to fomite contact risk estimates that are four orders of magnitude lower than those for diarrhoeal events. The estimated risk of secondary illness from touching a common surface is as high as 25% (1:4) after single fomite exposure following a diarrhoeal event.

CONCLUSIONS

A single fomite contact may lead to sizable risk of norovirus infection in ESWs if personal protective equipment and disinfection are not used appropriately. ESWs can also transfer virus to secondary surfaces, initiating further infections. Interventions are needed to reduce fomite transfer of norovirus, and protect patients and staff from nosocomial infections.

Controlling risk of SARS-CoV-2 infection in essential workers of enclosed food manufacturing facilities

The SARS-CoV-2 global pandemic poses significant health risks to workers who are essential to maintaining the food supply chain. Using a quantitative risk assessment model, this study characterized the impact of risk reduction strategies for controlling SARS-CoV-2 transmission (droplet, aerosol, fomite-mediated) among front-line workers in a representative indoor fresh fruit and vegetable manufacturing facility. We simulated: 1) individual and cumulative SARS-CoV-2 infection risks from close contact (droplet and aerosols at 1–3 m), aerosol, and fomite-mediated exposures to a susceptible worker following exposure to an infected worker during an 8 h-shift; and 2) the relative reduction in SARS-CoV-2 infection risk attributed to infection control interventions (physical distancing, mask use, ventilation, surface disinfection, hand hygiene, vaccination). Without mitigation measures, the SARS-CoV-2 infection risk was largest for close contact (droplet and aerosol) at 1 m (0.96, 5th – 95th percentile: 0.67–1.0). In comparison, risk associated with fomite (0.26, 5th – 95th percentile: 0.10–0.56) or aerosol exposure alone (0.05, 5th – 95th percentile: 0.01–0.13) at 1 m distance was substantially lower (73–95%). At 1 m, droplet transmission predominated over aerosol and fomite-mediated transmission, however, this changed by 3 m, with aerosols comprising the majority of the exposure dose. Increasing physical distancing reduced risk by 84% (1–2 m) and 91% (1–3 m). Universal mask use reduced infection risk by 52–88%, depending on mask type. Increasing ventilation (from 0.1 to 2–8 air changes/hour) resulted in risk reductions of 14–54% (1 m) and 55–85% (2 m). Combining these strategies, together with handwashing and surface disinfection, resulted in <1% infection risk. Partial or full vaccination of the susceptible worker resulted in risk reductions of 73–92% (1 m risk range: 0.08–0.26). However, vaccination paired with other interventions (ACH 2, mask use, or distancing) was necessary to achieve infection risks <1%. Current industry SARS-CoV-2 risk reduction strategies, particularly when bundled, provide significant protection to essential food workers.

Controlling risk of SARS-CoV-2 infection in essential workers of enclosed food manufacturing facilities

The SARS-CoV-2 global pandemic poses significant health risks to workers who are essential to maintaining the food supply chain. Using a quantitative risk assessment model, this study characterized the impact of risk reduction strategies for controlling SARS-CoV-2 transmission (droplet, aerosol, fomite-mediated) among front-line workers in a representative enclosed food manufacturing facility. We simulated: 1) individual and cumulative SARS-CoV-2 infection risks from close contact (droplet and aerosols at 1-3m), aerosol, and fomite-mediated exposures to a susceptible worker following exposure to an infected worker during an 8h-shift; and 2) the relative reduction in SARS-CoV-2 infection risk attributed to infection control interventions (physical distancing, mask use, ventilation, surface disinfection, hand hygiene). Without mitigation measures, the SARS-CoV-2 infection risk was largest for close contact (droplet and aerosol) at 1m (0.96, 95%CI: 0.67-1.0). In comparison, risk associated with fomite (0.26, 95%CI: 0.10-0.56) or aerosol exposure alone (0.05, 95%CI: 0.01-0.13) at 1m distance was substantially lower (73-95%). At 1m, droplet transmission predominated over aerosol and fomite-mediated transmission, however, this changed by 3m, with aerosols comprising the majority of the exposure dose. Increasing physical distancing reduced risk by 84% (1 to 2m) and 91% (1 to 3m). Universal mask use reduced infection risk by 52-88%, depending on mask type. Increasing ventilation (from 0.1 to 2-8 air changes/hour) resulted in risk reductions of 14-54% (1m) and 55-85% (2m). Combining these strategies, together with handwashing and surface disinfection, resulted in <1% infection risk. Current industry SARS-CoV-2 risk reduction strategies, particularly when bundled, provide significant protection to essential food workers.

SIGNIFICANCE STATEMENT

Using mathematical modeling, we find that workers in enclosed food manufacturing facilities are at higher risk of SARS-CoV-2 infection from close contact transmission (exposure to large droplets and small aerosol particles) than fomite transmission. Thus, strategies protecting workers should prioritize close contact transmission pathways, such as physical distancing, universal mask use, and room air changes, with surface disinfection (reducing fomite transmission) and handwashing of secondary importance. Our work supports current international (EU-OSHA), domestic (FDA, OSHA), and food industry-standard guidance for managing COVID-19 transmission in essential workers in the food manufacturing sector. Although our model was designed for an indoor food manufacturing setting, it can be readily adapted to other indoor environments and infectious respiratory pathogens.

Scientific Evidence Supports the Use of Alcohol-Based Hand Sanitizers as an Effective Alternative to Hand Washing in Retail Food and Food Service Settings When Heavy Soiling Is Not Present on Hands

ABSTRACT

Suboptimal food worker health and hygiene has been a common contributing factor in foodborne disease outbreaks for many years. Despite clear U.S. Food and Drug Administration (FDA) Model Food Code recommendations for hand washing and glove use, food worker compliance with hand washing recommendations has remained poor for >20 years. Food workers' compliance with recommended hand washing guidelines is adversely impacted by a number of barriers, including complaints of time pressure, inadequate number and/or location of hand washing sinks and hand washing supplies, lack of food knowledge and training regarding hand washing, the belief that wearing gloves obviates the need for hand washing, insufficient management commitment, and adverse skin effects caused by frequent hand washing. Although many of the issues related to poor hand washing practices in food service facilities are the same as those in health care settings, a new approach to health care hand hygiene was deemed necessary >15 years ago due to persistently low compliance rates among health care personnel. Evidence-based hand hygiene guidelines for health care settings were published by both the Centers for Disease Control and Prevention in 2002 and by the World Health Organization in 2009. Despite similar low hand washing compliance rates among retail food establishment workers, no changes in the Food Code guidelines for hand washing have been made since 2001. In direct contrast to health care settings, where frequent use of alcohol-based hand sanitizers (ABHSs) in lieu of hand washing has improved hand hygiene compliance rates and reduced infections, the Food Code continues to permit the use of ABHSs only after hands have been washed with soap and water. This article provides clear evidence to support modifying the FDA Model Food Code to allow the use of ABHSs as an acceptable alternative to hand washing in situations where heavy soiling is not present. Emphasis on the importance of hand washing when hands are heavily soiled and appropriate use of gloves is still indicated.

HIGHLIGHTS

Assessing Employee Health Policies for Reporting and Excluding Ill Food Employees in Restaurants within the United States

ABSTRACT

Preventing ill food employees from spreading pathogens to food and food contact surfaces remains an important objective of retail food safety policy in the United States. Since 2005, the U.S. Food and Drug Administration (FDA) has recommended food establishments implement employee health policies that include requirements for the exclusion or restriction of ill food employees and reporting, to the person in charge, symptoms or diagnosis of certain diseases transmitted by food. However, the incorporation of this recommendation has not been widely studied. The purpose of this exploratory study was to assess the presence and prevalence of employee health policies at fast-food and full-service restaurants in the United States. More than 50% of fast-food and full-service restaurants were found to have nonexistent employee health policies for each of the five recommended components specified in the FDA Food Code. Results showed 17.41% of fast-food restaurants and 12.88% of full-service restaurants had all five recommended components. Moreover, most restaurants with all five recommended employee health policy components were part of a multiple-unit operation and were found to have more developed food safety management systems than restaurants with none of the recommended components. Further attention and research into the impediments associated with developing and implementing employee health policies in restaurants is warranted.

HIGHLIGHTS

Significance of norovirus in occupational health: a review of published norovirus outbreaks in Central and Northern Europe

Objectives

Globally, norovirus (NoV) is the leading cause of gastroenteritis infection among all ages. The development of prevention strategies in the field of occupational health requires a detailed knowledge about the impact of the disease on employees. This review article aims not only at evaluating the burden of NoV outbreaks on staff but also at discussing implications for future prevention strategies.

Methods

Published NoV outbreaks in Central and Northern Europe were identified via a systematic literature search. Additionally, published NoV outbreaks in Germany were detected via a manual literature search. Key epidemiological data, as the number of symptomatic staff, was then extracted. The proportion of affected employees was calculated for each dataset (single NoV outbreaks or aggregated data of multiple outbreaks).

Results

Overall, 116 datasets were extracted from 72 relevant articles. 144,852 persons were affected by NoV gastroenteritis, 25,408 out of them (17.5%) were employees. 23,874 (94.0%) of them fell sick during outbreaks in hospitals and related settings. NoV cases among personnel in food establishments were reported only sporadically (mean ratio: 0.01).

Conclusions

Employees in hospitals and community facilities seem quantitatively to be most vulnerable towards NoV epidemics. Therefore, high quality of prevention measures in these settings, respective compliance with prevention strategies should have the highest priority. The disease can be considered as an occupational disease, even regularly without long-term consequences. Following work safety rules, a vaccination for vulnerable groups should be recommended if the vaccine development turns out to be successful.

Electronic supplementary material

The online version of this article (10.1007/s00420-020-01543-4) contains supplementary material, which is available to authorized users.

An Agent-Based Model for Pathogen Persistence and Cross-Contamination Dynamics in a Food Facility

We used an agent-based modeling (ABM) framework and developed a mathematical model to explain the complex dynamics of microbial persistence and spread within a food facility and to aid risk managers in identifying effective mitigation options. The model explicitly considered personal hygiene practices by food handlers as well as their activities and simulated a spatially explicit dynamic system representing complex interaction patterns among food handlers, facility environment, and foods. To demonstrate the utility of the model in a decision-making context, we created a hypothetical case study and used it to compare different risk mitigation strategies for reducing contamination and spread of Listeria monocytogenes in a food facility. Model results indicated that areas with no direct contact with foods (e.g., loading dock and restroom) can serve as contamination niches and recontaminate areas that have direct contact with food products. Furthermore, food handlers' behaviors, including, for example, hygiene and sanitation practices, can impact the persistence of microbial contamination in the facility environment and the spread of contamination to prepared foods. Using this case study, we also demonstrated benefits of an ABM framework for addressing food safety in a complex system in which emergent system-level responses are predicted using a bottom-up approach that observes individual agents (e.g., food handlers) and their behaviors. Our model can be applied to a wide variety of pathogens, food commodities, and activity patterns to evaluate efficacy of food-safety management practices and quantify contamination reductions associated with proposed mitigation strategies in food facilities.

Final Consumer Options to Control and Prevent Foodborne Norovirus Infections

Norovirus (NoV) causes about one-fifth of all cases of foodborne diseases and is a foremost cause of domestically acquired foodborne acute gastroenteritis and outbreaks. NoV infections are often associated with the consumption of contaminated fresh and ready-to-eat produce, fresh and frozen berries, raw/undercooked bivalve mollusks and products which become contaminated during handling. Despite many industrial efforts to control and prevent NoV contamination of foods, the prevalence of NoV in high-risk foodstuffs at retail is still significant. Although certain consumer behaviors may even increase the risk of virus transmission, interventions aiming at changing/implementing consumer habits may be considered as opportunities for risk mitigation. This review aims at providing an update on the progress made in characterizing the effect that consumer habits, which are most critical to prevent NoV transmission (food choice and hygiene, disinfection and cooking during food preparation), may have on reducing the risk of NoV infection. A better understanding of the options for NoV control and prevention may be translated into innovative educational, social or even technological tools targeting consumers with the objective of mitigating the risk of NoV transmission.

Combining Quantitative Risk Assessment of Human Health, Food Waste, and Energy Consumption: The Next Step in the Development of the Food Cold Chain?

The preservation of perishable food via refrigeration in the supply chain is essential to extend shelf life and provide consumers with safe food. However, electricity consumed in refrigeration processes has an economical and an environmental impact. This study focuses on the cold chain of cooked ham, including transport, cold room in supermarket, display cabinet, transport by consumer, and domestic refrigerator, and aims to predict the risk for human health associated with Listeria monocytogenes, the amount of food wasted due to the growth of spoilage bacteria, and the electrical consumption to maintain product temperature through the cold chain. A set of eight intervention actions were tested to evaluate their impact on the three criteria. Results show that the modification of the thermostat of the domestic refrigerator has a high impact on food safety and food waste and a limited impact on the electrical consumption. Inversely, the modification of the airflow rate in the display cabinet has a high impact on electrical consumption and a limited impact on food safety and food waste. A cost-benefit analysis approach and two multicriteria decision analysis methods were used to rank the intervention actions. These three methodologies show that setting the thermostat of the domestic refrigerator to 4 °C presents the best compromise between the three criteria. The impact of decisionmaker preferences (criteria weight) and limitations of these three approaches are discussed. The approaches proposed by this study may be useful in decision making to evaluate global impact of intervention actions in issues involving conflicting outputs.

Advancing Retail Food Policy Debates: Estimating the Risk of Contaminated Servings of Food Attributed to Employee Food Handling Practices in Retail Food Establishments

Food employee contamination of ready-to-eat foods through improper food handling practices is an important contributing factor for foodborne illness in retail and food service establishments. Decreasing the incidence of improper food handling practices is a frequent topic of retail food policy deliberations that often involves estimating the degree to which a proposed policy might affect a specific food handling practice. However, the potential reduction in contaminated servings of food, and therefore foodborne illnesses avoided, associated with a given proposed policy change, is all too often uncertain. This article discusses the components, assumptions, and applications of the food handling practices model, a quantitative model that estimates the impact of food handling practices on servings of food moving along three consecutive stages: the contamination stage, the pathogen control stage, and the foodborne illness stage. To our knowledge, this article is the first time the model has been presented in an academic platform, and we also explore unique and interesting aspects of the model not addressed in publicly available documents. Risk-based estimates for contaminated servings of food attributed to changes in one or multiple food handling practices are derived that provide an important link between increased compliance with proper food handling practices and public health. Model estimates show that decreases in the incidence of inappropriate food handling practices lead to varying levels of contaminated food servings avoided, depending on the food handling practice. The ability to derive such estimates provides stakeholders and the general public with a means of understanding the relative impact of proposals to reduce improper food handling and to help inform regulatory food safety policy discussions and decision making.