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Leveraging Information To Improve Food Safety Management

RUTH L. PETRAN, PHD

29 April 2015

VP FOOD SAFETY & PUBLIC HEALTH, ECOLAB

Discussion Overview

Foodborne illness is a significant public health concern

Need to take action to drive rates down

Leverage available data to glean insights CDC contributing factors related to illnesses FDA risk factor studies Health department inspections Learnings from outbreaks

Identify mitigating strategies that will work At the restaurant level To guide R&D development efforts, etc.

Foodborne Illness Annual Estimates

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United States 48 million cases 120,000 hospitalizations 3000 deaths

Australia 4.1 million cases 86 deaths

EU 45.5 million cases

China - Surveillance beginning

Global foodborne illness estimate: 582 million cases & 351,000 deaths

Canada 4 million cases

South Korea 336,000 cases

Africa - Surveillance beginning

Where Was Contaminated Food Consumed?

Restaurant or deli57%

Private home12%

Hospital, Nursing Home 2%Banquet facility

13%

School4%

Church, temple1%

Prison, jail2%

Other9%

USA 2012

WHEN LOCATION IS KNOWN

Source: CDC 2014 http://www.cdc.gov/features/foodborne-diseases-data/?s_cid=cdc_homepage_feature_003

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Norovirus: Leading Cause of Foodborne IllnessTOP 5 US REPORTED OUTBREAKS (CONFIRMED AND SUSPECTED)

19931994

19951996

19971998

19992000

20012002

20032004

20052006

20072008

20092010

20112012

0

100

200

300

400

500

600

700

800

900

NorovirusSalmonellaC. perfringensE. coliCampylobacterUnknown

# O

utbr

eaks

Rep

orte

d

Source: http://www.cdc.gov/foodsafety/pdfs/foodborne-disease-outbreaks-annual-report-2012-508c.pdf

2014 Total Human Cost of Foodborne Illness

Salmonella is #1 cause of foodborne illness in terms of cost

Norovirus is #1 in terms of cases

Impact of : Size of Outbreak Severity of illness Complications Long term health effects

Total human cost of top 15 pathogens more than $15 billion annually

http://www.ers.usda.gov/data-products/cost-estimates-of-foodborne-illnesses.aspx

Norovirus Salmonella Listeria

Mean Annual Cost $2.3 Billion $3.7 Billion $2.8 Billion

Number of Cases 5.5 Million 1.2 Million 1,591 cases

Cost per Case$413 $3,568 $1.7 Million

Call to Action

The problem of food safety is significant. 1 in 6 of us suffers from a foodborne illness each year.

Clearly action is needed to drive rates of illnesses down, and to be most impactful, efforts need to be focused where they will have the biggest impact.

Leverage data to help guide efforts appropriately.

USA 2012

Adapted from CDC 2014 - http://www.cdc.gov/foodsafety/pdfs/foodborne-disease-outbreaks-annual-report-2012-508c.pdf

Improper Hold-ing 23%

Poor Personal Hygiene

30%Contaminated Equipment/

Environment 11%

Inadequate Cooking

14%

Unsafe Source 12%

Other11%

CDC Contributing Factors to Foodborne Illness

FDA Risk Factor Observational Studies

Done in food service & retail establishments 1998-2008 in three phases

Results Generally, there were improvements over time Risk Factors most in need of attention:

- Improper Holding/Time and Temperature- Poor Personal Hygiene- Contaminated Equipment/Protection from Contamination

Studies being repeated 2013-2025 One outcome is to assess impact of various industry and regulatory

intervention strategies

Health Department Inspections

Focus on factors contributing to foodborne illness

No consistent reporting format across the country

Certain jurisdictions posting results for consumers

Potential impact on consumer trust

Inspections Record Observed Violations

Millions of restaurant health department (HD) inspections done annually in US

Opportunity exists to mine data to determine role that inspection results can play in helping to identify risks

From this, identify major, modifiable risks

Focus efforts appropriately

US Model Food Code Is Basis For Restaurant Inspections

A uniform set of provisions that address the safety & protection of food offered at retail and in food service

A model to safeguard public health & ensure food is not adulterated

Guidance document from FDA that evaluates: Foodborne illness risk factors Good retail practices

Adopted by local & state health departments in a variety of ways Requirements vary among jurisdictions Frequency of inspections and scoring varies among jurisdictions

Health Dept Insight: State VariabilityAverage Total Findings By State

High Variability in Total Findings from State to State

Most Findings

Kansas 5.5

Connecticut 5.3

Oklahoma 5.1

Nebraska 5.1

Tennessee 5.1

Least Findings

Mississippi 0.4

Washington 1.3

Nevada 1.5

Arizona 1.5

Arkansas 1.6

  0-1  1-2  2-3  3-4  4-5  5+

Health Dept Insight: Top Findings

3 of the 5 Top Findings May Directly Result in Food Borne Illness

Most Commonly Cited Issues 2011-2013

Item Level Frequency

Physical facilities installed, maintained, and clean GRP 31.5%

Food contact surfaces are clean and sanitized FBI 29.0%

Food and non-food contact surfaces cleanable, properly designed, constructed, and used

GRP 27.3%

Adequate hand-washing sinks – properly supplied and accessible

FBI 18.9%

Proper cold holding temperatures FBI 17.4%

Top HD Violations Overall

Top 10 Violations for Specific Chain Industry All (2,587)

Q53-Physical facilities installed, maintained and clean 12.10%

Q20-Proper cold holding temperatures 4.67%Q45-Food and non food-contact surfaces cleanable, properly designed, constructed and used 9.26%

Q47-Nonfood-contact surfaces clean 8.99%

Q49-Plumbing installed; proper backflow devices 4.52%

Q8-Adequate handwashing sinks properly supplied and accessible 6.12%

Q14-Food-contact surfaces: cleaned and sanitized 9.93%

Q54-Adequate ventilation and lighting; designated areas use 2.71%

Q42-Utensils, equipment and linens: properly stored, dried and handled 3.00%

Q37-Contamination prevented during food preparation, storage and display 4.23%

Use Data to Drive Improvements

Understanding risks is the starting point

Changing the food safety behaviors of individuals requires a total system approach, including: Education and Manager Certifications Inspections and Audits Hands-on training Motivation and Encouragement

Focused service, training and procedures Having a Certified Manager onsite reduces violations by 24% Completing daily Food Safety Logs reduces violations by 44% Restaurants that submit Corrective Actions average 22% less

findings

How to Best Leverage Data

Analyze the data to identify trends Which locations/regions to focus on What type of solution might have the biggest effect?

Ask for help How could your vendors help you

- What solutions or tools do they have- What could they develop for you

Should you reach out to a training provider

Look for ways to verify that solutions are effective Continue to analyze data

Connecting the dots…

CDC Data - Top Risk Factors for FBI

1. Improper Holding Temperatures

2. Poor Personal Hygiene

3. Inadequate Cooking

4. Unapproved Source

5. Contaminated Equipment

HD Data - Top reasons restaurants fail inspections

1. Food and non food-contact surfaces cleanable, properly designed, constructed and used

2. Physical facilities installed, maintained and clean

3. Food-contact surfaces: cleaned and sanitized

4. Nonfood-contact surfaces clean

5. Adequate handwashing sinks properly supplied and accessible

Illustration: HD Data Research

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Methodology: Compared routine health inspection data between outbreak and non-outbreak restaurants

Results: • Identified 11 key violations linked to outbreak restaurants• Surprisingly, many were Good Retail Practices, not critical risks of

foodborne illness

Source:Petran et al. 2012.JFP 75(11):2007-2015.

Example 1: Contaminated Equipment & Food Contact Surfaces Cleaned and Sanitized

Understand the flow of food through your establishment

Understand where there is a possibility of cross-contamination

Set up barriers and procedures to block pathogen transfer and growth

Use proper sanitization procedures and chemicals, following the label instructions

Make sure your kitchen is free of pests

#1 Real Life Outbreak

14 patrons at a food service establishment became ill

Two hospitalizations. Camplybacter jejuni isolated from all patients

Investigation revealed multiple sources of contamination Countertop too small to separate raw poultry and other foods Cook cut up raw chicken before preparing salads Lettuce for salads was shredded with a knife Cook wore a towel around her waist, frequently used to dry hands Uncertain whether the cook had cleaned the countertop after cutting

up the chicken

Lettuce likely contaminated with raw chicken

http://www.cdc.gov/mmwr/preview/mmwrhtml/00051427.htm

#1 Response: Offerings from a Coach or Provider Contamination prevention

Hand care programs Cleaning & sanitation products,

equipment and services Supply chain antimicrobial

treatments for meat, poultry, and produce

Color coded equipment Pest elimination Hand care compliance

Example 2: Poor Personal Hygiene & Adequate Handwashing Guidelines

Food Code Reference (2013)

Description

2-301.12 Hands and Arms - Cleaning Procedures

5-203.11A Provide the number of handwash sinks necessary for the convenient use of employees in food preparation, dispensing, and warewashing area

5-203.11C Use chemically treated towelettes for handwashing a vending machine locations…

5-204.11 Locate a handwashing sink to allow convenient use in food preparation, food dispensing, and Warewashing Areas.…

5-205.11 Maintain a hand washing sink so it is accessible at all times…

6-301.12A Provide and maintain at each handwash sink… a supply of individual disposable towels…

6-501.18 Clean and maintain the handwashing sinks.

Avoid unsanitary habits

Maintain and monitor their personal health

Report illness and wounds

Follow hygienic hand practices: good hand washing and proper glove use

#2 Real Life Outbreak

Guests at different events received sandwiches from common source

≥100 people estimated to be affected

Illness associated with sandwiches containing lettuce

Employee with norovirus symptoms returned to work the same day that symptoms ended

Was still excreting norovirus in his stool

Food prep sink used to wash lettuce also used for hand washing

Food handlers can contaminate food and cause consumers to become ill

Source - MMWR 55(14):395-7

#2 Response: Offerings from a Coach or Provider

Heath Department – Top Violations

Address Staff Behavior Offer Tools & Products

Adequate handwashing sinks properly supplied and accessible

Wash after cough

Blocked Sink

Wash before glove

Towels not available

Soap not available

Signs not posted

• Onsite Review & Coaching • Suggestion of products• Solutions that influence behavior

Example 3: Improper Holding Temperatures Tied to Foodborne Illness

Can allow pathogens to persist and in some cases, increase to harmful levels

Proper hot and cold holding are crucial to food safetyKeep food out of the Temperature

Danger Zone- Below 41˚F (5˚C) and above 135˚F (57˚C)

Monitor proper temperature control with a calibrated thermometer

Use equipment designed for keeping food at the proper temperature

#3 Foodborne Illness Intoxications

Illness attributed to C. perfringens, B. cereus and S. aureus

Account for 1.3 million illnesses each year 14% of the 9.4 million illnesses

Spores are frequent contaminants Cooking activates the spores allowing for rapid growth of cells These cells grow much faster than other types of bacteria

Cells grow in food with poor temperature control Inadequate cooling or cold holding are key risk factors

How significant of an issue is this?

Source: Scallan, et al. 2011.

#3 Real Life Outbreak

Typically large numbers of people are affected Under-reporting factor is very large

Between 1998 and 2008, improper cooling practices contributed to 504 outbreaks in foodservice settings. (CDC, 2012)

Pasta Salad http://jcm.asm.org/content/43/8/4277.full

Prepared on Friday for Saturday picnic. Leftovers stored in refrigerator (set at 57F) & consumed on Monday night

1 child died High levels of B. cereus toxin found in salad

#3 Cold Holding Data

On-site data collection at 420 restaurants & 596 foods 69% chains and 31% independents, most served “American” menu Cooling methods: refrigerator>ice bath>room temp>ice wand>blast

16% of ambient temps in cooling units were >41F Reach-in coolers were among the worst

Other observations: Depths not shallow enough, Limited ventilation, Stacked foods on

top of each other, Lack of ice in ice baths

Most managers reported being trained, yet… Did not monitor time or temp 41% of time Thermometer calibration issues 31% of time

Source: Brown, et al. 2012. JFP 75(12)2172

#3 Response: Offerings to Mitigate

Recognize that problem exists Cold Hold #1 or #2 issue

Target interventions appropriately Equipment - ambient air temp, machine maintenance issues,

gaskets in poor repair, thermostat not set properly… Behaviors - containers filled too high, improper pre-chill, importance

of monitoring & verification Cooling devices

Call to Action!

Parting Thoughts

How could data from inspections and industry be used? In R&D development chemistry and equipment efforts Insight on where to focus training and coaching Broad service solutions

Can this be tied to foodborne illness decrease?

Goal: Move from Information to Action!

Consider… what can you do to prevent another outbreak from being attributed to

one of these factors?

Questions?