Retail Deli Slicer Inspection Practices: An EHS-Net Study

Restaurant and Staff Characteristics Related to Practices that Could Contribute to Cross-Contamination

Foodborne illness is a persistent public health concern in the U.S.; over 800 foodborne illness outbreaks are reported to the Centers for Disease Control and Prevention (CDC) annually. Most of these outbreaks (60%) are linked with restaurants. Contamination of food with foodborne pathogens during preparation and storage is a significant contributing factor to many of these outbreaks. The CDC's Environmental Health Specialists Network (EHS-Net) collected data to identify restaurant characteristics, policies, and practices associated with contamination prevention practices. Data collectors interviewed managers and conducted kitchen observations in 312 restaurants across six EHS-Net sites in five states. Data collectors observed at least one food worker action that could lead to contamination in 63.1% of restaurants. The most frequently observed action that could lead to contamination was bare-hand or dirty glove contact with ready-to-eat food (35.9%). The estimated mean number of observed potential contamination actions was greater in restaurants that were independently owned (does not share a name and operations with other restaurants), did not require managers to be certified in food safety, did not have workers trained in food safety, did not have a handwashing policy, did not have a policy minimizing bare-hand contact with ready-to-eat foods, and had a manager with more than two years of experience at their current restaurant. These results suggest that to improve contamination prevention, the foodservice industry and food safety officials can consider supporting and encouraging strong food safety training and policies, particularly concerning hand hygiene, and targeting interventions to independent restaurants.

Two Listeria monocytogenes outbreaks in a cancer centre: onsite food premises and their potential health risk to patients

BACKGROUND

This report describes two L. monocytogenes outbreak investigations that occurred in March and September of 2018 and that linked illness to a food premises located in an Ontario cancer centre. The cancer centre serves patients from across the province.

METHODS

In Ontario, local public health agencies follow up with all reported laboratory-confirmed cases of listeriosis to identify possible sources of disease acquisition and to carry out investigations, including at suspected food premises. The Canadian Food Inspection Agency (CFIA) is notified of any Listeria-positive food product collected in relation to a case. The CFIA traces Listeria-positive product through the food distribution system to identify the contamination source and ensure the implicated manufacturing facility implements corrective measures.

RESULTS

Outbreaks one and two each involved three outbreak-confirmed listeriosis cases. All six cases were considered genetically related by whole genome sequencing (WGS). In both outbreaks, outbreak-confirmed cases reported consuming meals at a food premises located in a cancer centre (food premises A) before illness onset. Various open deli meat samples and, in outbreak two, environmental swabs (primarily from the meat slicer) collected from food premises A were genetically related to the outbreak-confirmed cases. Food premises A closed as a result of the investigations.

CONCLUSIONS

When procuring on-site food premises, healthcare facilities and institutions serving individuals with immuno-compromising conditions should consider the potential health risk of foods available to their patient population.

Restaurant Date-Marking Practices Concerning Ready-to-Eat Food Requiring Time and Temperature Control for Safety

Certain foods are more vulnerable to foodborne pathogen growth and formation of toxins than others. Lack of time and temperature control for these foods can result in the growth of pathogens, such as Listeria monocytogenes, and lead to foodborne outbreaks. The Food and Drug Administration's (FDA) Food Code classifies these foods as time/temperature control for safety (TCS) foods and details safe cooking, holding, and storing temperatures for these foods. The FDA Food Code also includes a date-marking provision for ready-to-eat TCS foods that are held for >24 h. The provision states that these foods should not be held in refrigeration for >7 days and should be marked with the date or day by which the food should be "consumed on the premises, sold, or discarded." To learn more about restaurants' date-marking practices, the Centers for Disease Control and Prevention's Environmental Health Specialists Network (EHS-Net) conducted observations and manager interviews in 359 restaurants in 8 EHS-Net jurisdictions. Managers reported that they date marked ready-to-eat TCS foods more often than data collectors observed this practice (91% vs. 77%). Observation data showed almost a quarter of study restaurants did not date-mark ready-to-eat TCS foods. In addition, restaurants with an internal date-marking policy date marked 1.25 times more often than restaurants without such a policy and chain restaurants date marked 5.02 times more often than independently owned restaurants. These findings suggest that regulators and the retail food industry may improve food safety and lower the burden of foodborne illness in the United States if they target interventions to independent restaurants and encourage strong date-marking policies.

Observed Potential Cross-Contamination in Retail Delicatessens

ABSTRACT

Listeria monocytogenes is a persistent public health concern in the United States and is the third leading cause of death from foodborne illness. Cross-contamination of L. monocytogenes (between contaminated and uncontaminated equipment, food, and hands) is common in delicatessens and likely plays a role in the foodborne illness associated with retail deli meats. In 2012, the Centers for Disease Control and Prevention's Environmental Health Specialists Network conducted a study to describe deli characteristics related to cross-contamination with L. monocytogenes. The study included 298 retail delis in six state and local health departments' jurisdictions and assessed how well deli practices complied with the U.S. Food and Drug Administration Food Code provisions. Among delis observed using wet wiping cloths for cleaning, 23.6% did not store the cloths in a sanitizing solution between uses. Observed potential cross-contamination of raw meats and ready-to-eat foods during preparation (e.g., same knife used on raw meats and ready-to-eat foods, without cleaning in between) was present in 9.4% of delis. In 24.6% of delis with a cold storage unit, raw meats were not stored separately from ready-to-eat products in containers, bins, or trays. A proper food safety management plan can reduce gaps in cross-contamination prevention and should include adopting procedures to minimize food safety risks, instituting training with instruction and in-person demonstrations and certifying staff on those procedures, and monitoring to ensure the procedures are followed.

HIGHLIGHTS

Occurrence of Listeria monocytogenes in Counter-Sliced Turkey Meat Samples from Independent Delis in New York City

ABSTRACT

Research suggests that small, independent delicatessens are less likely to follow proper sanitation procedures, including slicer inspection, which could lead to a higher likelihood of these delis being a reservoir for Listeria monocytogenes growth and cross-contamination. This study was undertaken to determine the incidence of L. monocytogenes in counter-sliced turkey deli meat obtained from independent delis in an urban city. Deli meat, counter-sliced on site, was collected from 118 independent delis in New York City. The samples were analyzed for L. monocytogenes using the U.S. Department of Agriculture Microbiology Laboratory Guidebook methodology for isolation and confirmation. The selection criteria for delis included using the city's restaurant inspection and grading system. Two samples, from separate delis, were confirmed as positive for L. monocytogenes (1.69%). Analysis of the genomic sequences of one of the samples revealed a close match to a cluster of six clinical isolates, which were part of an ongoing multistate listeriosis outbreak spanning four states. The sequence of the second isolate matched a clinical isolate in a neighboring state. Both isolates were obtained from delis that did not have the top inspection grade. Although a snapshot of one urban area, this study is the first report on the current incidence of L. monocytogenes on counter-sliced deli meat from independent deli establishments. This study suggests that these delis can potentially serve as sources of L. monocytogenes contamination or contribute to downstream foodborne listeriosis. Information provided by city inspection and grading systems, in addition to the letter grade, may serve as a tool to identify delis with potential L. monocytogenes contamination issues and a basis for product and environmental sampling by public health authorities.

HIGHLIGHTS

Retail Deli Characteristics Associated with Sanitizing Solution Concentrations

ABSTRACT

Listeria monocytogenes is commonly found in retail delicatessen environments. Proper types and concentrations of sanitizers must be used to eliminate this pathogen from surfaces and reduce the consumer's risk for infection. In 2012, the Environmental Health Specialists Network of the Centers for Disease Control and Prevention completed a study on practices in retail delis that can help prevent cross-contamination and growth of L. monocytogenes. The present study focuses on the sanitizing solution used in delis, given its importance to cleaning and reducing pathogen contamination in retail food environments. We identified deli, manager, and worker characteristics associated with use of improper concentrations of sanitizing solution to wipe down food contact surfaces; 22.8% of sanitizing solutions used for wiping food contact surfaces were at improper concentrations. Independent delis were more likely to use improper concentrations of sanitizing solution, as were delis that sold fewer chubs (plastic tubes of meat) per week. Use of improper sanitizing solution concentrations was associated with required food safety training for managers; additional analyses suggest that this relationship is significant for independent but not chain delis. Cleaning and sanitizing must be emphasized in food safety efforts focused on independent and smaller delis.

HIGHLIGHTS

Restaurant Policies and Practices Related to Norovirus Outbreak Size and Duration

ABSTRACT

Norovirus is the leading cause of foodborne illness outbreaks in the United States, and restaurants are the most common setting of foodborne norovirus outbreaks. Therefore, prevention and control of restaurant-related foodborne norovirus outbreaks is critical to lowering the burden of foodborne illness in the United States. Data for 124 norovirus outbreaks and outbreak restaurants were obtained from Centers for Disease Control and Prevention surveillance systems and analyzed to identify relationships between restaurant characteristics and outbreak size and duration. Findings showed that restaurant characteristics, policies, and practices were linked with both outbreak size and outbreak duration. Compared with their counterparts, restaurants that had smaller outbreaks had the following characteristics: managers received food safety certification, managers and workers received food safety training, food workers wore gloves, and restaurants had cleaning policies. In addition, restaurants that provided food safety training to managers, served food items requiring less complex food preparation, and had fewer managers had shorter outbreaks compared with their counterparts. These findings suggest that restaurant characteristics play a role in norovirus outbreak prevention and intervention; therefore, implementing food safety training, policies, and practices likely reduces norovirus transmission, leading to smaller or shorter outbreaks.

HIGHLIGHTS

Listeria monocytogenes Occurrence and Adherence to Recommendations: Small and Large Retail Delicatessens in Iowa

The goal of this research was to determine the prevalence of Listeria monocytogenes in Iowa retail delicatessens and assess environmental aspects that mitigate L. monocytogenes. Fifty-seven small and large retail delicatessens in Iowa were selected randomly. More small operations (n = 43) were included as compared with larger stores, given the higher frequency of violations. An environmental assessment instrument was used to determine environmental factors and practices. At least five microbial samples were collected per site. We collected 286 (74.3%) of 385 microbial samples from small deli operations and 99 (25.7%) of 385 samples from large deli operations. Samples were taken from various zone 1 and 2 areas, such as the slicer, deli case, and meat scale; three (0.08%) samples were positive for L. monocytogenes. Regarding environmental aspects, not preparing, holding or storing ready-to-eat products near raw products (n = 30, 53%) was practiced by the fewest delis. The majority of establishments were observed covering, wrapping, or protecting ready-to-eat products when not in use to prevent contamination (n = 56, 98.2%). Comparisons were made to the U.S. Department of Agriculture Food Safety and Inspection Service Guidance on environmental practices, and 60% of the operations surveyed were in adherence with at least seven of the eight recommendations.

Restaurant Characteristics Associated With the Use of Specific Food-Cooling Methods

Pathogen growth caused by improper or slow cooling of hot foods was a contributing factor in 504 of restaurant- and deli-related outbreaks in the U.S. from 1998-2008. Little is known, however, about restaurant cooling practices. To fill this gap, the Centers for Disease Control and Prevention's Environmental Health Specialists Network (EHS-Net) conducted an observational study to identify and understand factors that might determine which methods restaurants follow to rapidly cool food. These methods include refrigerating food at ≤41 °F, at shallow depths, and in containers that are ventilated, unstacked, and have space around them. EHS-Net personnel collected data through manager interviews and observation of cooling processes in 420 randomly selected restaurants. Regression analyses revealed characteristics of restaurants most likely to use the cooling methods assessed. These characteristics included ownership by restaurant chains, manager food safety training and certification, few foods cooled at a time, many meals served daily, and a high ratio of workers to managers. These findings suggest that regulatory food safety programs and the retail industry might improve cooling methods-and reduce outbreaks-by providing and encouraging manager food safety training and certification, and by focusing intervention efforts on independent and smaller restaurants.

Foodborne Illness Outbreaks at Retail Establishments - National Environmental Assessment Reporting System, 16 State and Local Health Departments, 2014-2016

PROBLEM/CONDITION

State and local public health departments report hundreds of foodborne illness outbreaks each year to CDC and are primarily responsible for investigations of these outbreaks. Typically, investigations involve epidemiology, laboratory, and environmental health components. Health departments voluntarily report epidemiologic and laboratory data from their foodborne illness outbreak investigations to CDC through the Foodborne Disease Outbreak Surveillance System (FDOSS); however, minimal environmental health data from outbreak investigations are reported to FDOSS.

PERIOD COVERED

2014-2016.

DESCRIPTION OF SYSTEM

In 2014, CDC launched the National Environmental Assessment Reporting System (NEARS) to complement FDOSS surveillance and to use these data to enhance prevention efforts. State and local health departments voluntarily report data from their foodborne illness outbreak investigations of retail food establishments. These data include characteristics of foodborne illness outbreaks (e.g., agent), characteristics of establishments with outbreaks (e.g., number of meals served daily), food safety policies and practices of these establishments (e.g., glove use policies), and characteristics of outbreak investigations (e.g., timeliness of investigation activities). NEARS is the only available data source that includes characteristics of retail establishments with foodborne illness outbreaks.

RESULTS

During 2014-2016, a total of 16 state and local public health departments reported data to NEARS on 404 foodborne illness outbreaks at retail establishments. The majority of outbreaks with a suspected or confirmed agent were caused by norovirus (61.1%). The majority of outbreaks with identified contributing factors had at least one factor associated with food contamination by a worker who was ill or infectious (58.6%). Almost half (47.4%) of establishments with outbreaks had a written policy excluding ill workers from handling food or working. Approximately one third (27.7%) had a written disposable glove use policy. Paid sick leave was available for at least one worker in 38.3% of establishments. For most establishments with outbreaks (68.7%), environmental health investigators initiated their component of the investigation soon after learning about the outbreak (i.e., the same day) and completed their component in one or two visits to the establishment (75.0%). However, in certain instances, contacting the establishment and completing the environmental health component of the investigation occurred much later (>8 days).

INTERPRETATION

Most outbreaks reported to NEARS were caused by norovirus, and contamination of food by workers who were ill or infectious contributed to more than half of outbreaks with contributing factors; these findings are consistent with findings from other national outbreak data sets and highlight the role of workers in foodborne illness outbreaks. The relative lack of written policies for ill workers and glove use and paid sick leave for workers in establishments with outbreaks indicates gaps in food safety practices that might have a role in outbreak prevention. The environmental health component of the investigation for most outbreaks was initiated quickly, yet the longer initiation timeframe for certain outbreaks suggests the need for improvement.

PUBLIC HEALTH ACTION

Retail establishments can reduce viral foodborne illness outbreaks by protecting food from contamination through proper hand hygiene and excluding workers who are ill or infectious from working. NEARS data can help prioritize training and interventions for state and local food safety programs and the retail food establishment industry by identifying gaps in food safety policies and practices and types of establishments vulnerable to outbreaks. Improvement of certain outbreak investigation practices (e.g., delayed initiation of environmental health investigations) can accelerate identification of the agent and implementation of interventions. Future analysis comparing establishments with and without outbreaks will contribute knowledge about how establishments' characteristics and food safety policies and practices relate to foodborne illness outbreaks and provide information to develop effective prevention approaches.