What food professionals should take away from CDC’s recent report, “Foodborne Illness Outbreaks at Retail Food Establishments…”

Foodborne Illness Outbreaks at Retail Food Establishments – National Environmental Assessment Reporting System, 25 State and Local Health Departments, 2017 – 2019   June 2, 2023
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INTRODUCTION

Each year, local health authorities voluntarily report hundreds of foodborne illness outbreaks associated with retail food establishments (e.g. restaurants or caterers) to CDC. An outbreak is declared upon two or more reports of similar symptoms from a common location or source. State and local health departments voluntarily report epidemiological (relating to the branch of medicine which deals with the incidence, distribution, and control of diseases) and laboratory data from their foodborne illness outbreak investigations to CDC through the National Outbreak reporting system (NORS). In the past, however, only minimal environmental health data is reported through NORS.

In 2014, CDC launched the National Environmental Assessment Reporting System, (NEARS) to complement NORS surveillance and to use these environmental data to enhance prevention efforts. Examples of environmental data are, for example, the number of meals served daily in the subject operation, independent or chain affiliation, and the presence and quality of employee health reporting. That’s the end game… learning from all possible data types to prevent future occurrences.

RESULTS

During 2017–2019, a total of 800 foodborne illness outbreaks associated with 875 retail food establishments were reported to NEARS by 25 state and local health departments.

• 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. This is important, because it it preventible. Investigators conducted an interview with an establishment manager in 679 (84.9%) outbreaks. Of the 725 managers interviewed, most (91.7%) said their establishment had a policy requiring food workers to notify their manager when they were ill, and 66.0% also said these policies were written. Only 23.0% said their policy listed all five illness symptoms workers needed to notify managers about (i.e., vomiting, diarrhea, jaundice, sore throat with fever, and lesion with pus). Although a majority of managers reported their establishment had an ill worker policy, often these policies were missing components intended to reduce foodborne illness risk. Contamination of food by ill or infectious food workers is an important cause of outbreaks; therefore, the content and enforcement of existing policies might need to be re-examined and refined.

• Most interviewees (85.5%) said that their establishment had a policy restricting or excluding ill workers from working, and 62.4% said these policies were written. Only 17.8% said their policy listed all five illness symptoms that would require restriction or exclusion from work. Only 16.1% of establishments with outbreaks had policies addressing all four components relating to ill or infectious workers.Such a policy:

• required workers to tell a manager when they are ill,
• specified the five symptoms of foodborne illness workers need to report to their manager (i.e., vomiting, diarrhea, jaundice, sore throat with fever, and lesion with pus),
• restricted (i.e., prevented from handling food) or excluded (i.e., prevented from working) ill or infectious workers, and
• specified the five symptoms requiring worker restriction or exclusion from work activities.

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• Although a majority of managers reported their establishment had an ill worker policy, often these policies were missing components intended to reduce foodborne illness risk. Contamination of food by ill or infectious food workers is an important cause of outbreaks; therefore, the content and enforcement of existing policies might need to be re-examined and refined.

• Food workers report numerous reasons for working when ill, such as loss of pay and perceived social pressure. NEARS data demonstrate that fewer than half of establishments with outbreaks provided paid sick leave to at least one food worker. Research suggests that paid sick leave might improve food safety outcomes. Expanded paid sick leave in a restaurant chain reduced the incidence of working while ill among front-line food service workers, and supportive paid sick leave regulations were found to be associated with decreased foodborne illness rates. A multilayered approach addressing implementation and enforcement might be required to prevent ill employees from working. Such an approach not only includes adoption and enforcement of comprehensive written ill worker policies but also enhances training, management plans to continue operations when a worker is absent (e.g., on-call staffing), and adoption of a food safety culture where absenteeism due to illness is not penalized.

• The most common (pathogen) proliferation contributing factor was improper or slow cooling of hot food (53 [10.6%]), and the most common (pathogen) survival contributing factor was insufficient time or temperature during cooking or heat processing (33 [6.6%]).

• A majority of establishments with outbreaks were independently owned (473 of 725 [65.2%]) and served ≤300 meals (upper range = 8,500 meals) daily (440 of 725 [60.7%]) Most were restaurants (712 of 875 [81.4%]), and 84.0% (735 of 875) served complex food items. Complex food items require a kill step (i.e., a process, such as cooking, that reduces or eliminates foodborne illness pathogens) and holding beyond same-day service, or a kill step and a combination of holding, cooling, reheating, and freezing. The most common menu type was American (485 of 875 [55.4%]). A majority (624 of 875 [71.3%]) of establishments received at least one critical violation on their last routine inspection before the outbreak.