There are several levels of disease prevention in food safety, from the farm to food production factories, to distribution, and then to food service from restaurants, commercial kitchens, or retail food stores.  We would like to have a magic bullet to help the food industry make all foods completely safe, but that’s a tough challenge since we involve imperfect humans handling foods.  The handling step—with our hands—is where we can make crucial mistakes in a food service kitchen.  

Our hands and fingers are the worst cross-contaminators.  Microorganisms hike around the kitchen on hands.   So to achieve safer food, we will always have to rely on three very important interventions that work as partners, so to speak.  In 1999, a very educated group of professionals referred to as the National Advisory Committee for Microbiological Criteria for Foods (NACMCF) made a strong impact on the food industry by officially reinforcing that we need more than handwashing alone as a preventative measure to reduce foodborne disease when handling ready-to-eat foods.   Handwashing is part of the equation, but not the only intervention we need.

The Fecal Oral Route – Most diseases from food are transmitted via the fecal / hand / oral route.  That means fecal pathogens get to hands or fingertips, we handle food, and that contaminated food goes into someone’s mouth or oral cavity.  More simply, a food handler doesn’t wash hands after using the restroom.   NACMCF concluded that bare hand contact with ready-to-eat foods definitely contributes to the transmission of foodborne illness and they also agreed that we could interrupt that transmission with 3 strategies or interventions.

The 3 Imperfect Interventions to Strive for – All three of these must work together to get us to a higher level of food safety and hand hygiene.  One intervention alone doesn’t cut it to give us the very best protection. 

1. Restriction or exclusion of ill food workersis the first preventative strategy.  The FDA Food Code has expanded the guidance on this subject in chapter 2.   We know that this strategy has its limitations because people do unfortunately come to work sick.  If we are being honest, who has not come to work in a restaurant when they were sick?  Most people have. Chefs and crew might do it because of short handed staffing, or they don’t want to take grief from coworkers or their manager. 

The Incentive to Work When Ill -- Hourly-wage workers may go to work and hide an illness transmittable through food to avoid losing pay.  The food industry does not often pay health care benefits for hourly wage workers, so there’s an economic incentive for people to want to work when sick—so they can get paid.   This strategy also has limitations because managers have a tough time trying to identify and manage asymptomatic food workers (those showing no symptoms of a disease, but are infected).  This fact makes it difficult for food managers to be completely effective at keeping sick workers out of the kitchen.

Reportable Foodborne Diseases – The Centers for Disease Control estimates that Norovirus is the leading cause of foodborne illness in the U.S.  Contaminated hands are a significant factor.  Food employees infected with fecal-oral pathogens can shed them through their stool at well over the levels to cause human infection through food via their hands.   The most dangerous, big 5 foodborne diseases that food workers must report to managers and the health department:  1) Salmonella Typhi, 2) E.coli 0157:H7, 3) Shigella, 4) Hepatitis A, and 5) Norovirus.  The FDA Food Code breaks down the risks of these types of diseases into four levels, describing when a food worker must be restricted or excluded from working in food service.   It’s a complicated issue.

2. Proper Handwashing is the next necessary strategy.  It’s the overall best thing we can do to control disease, but because again we are imperfect humans, we don’t always wash hands frequently enough, at the right time, or correctly with enough friction.   Depending on the microbial contamination level on the hands, handwashing with plain soap and water, as specified in the Food Code may not be an adequate intervention to prevent the transmission of pathogens from  bare hands to ready-to-eat foods.  Science has shown handwashing done correctly using the 20 second method in the Food Code is not enough protection from some low dose (doesn’t take many to make someone sick) pathogenic organisms found on fingertips.  This definitely includes viruses such as Norovirus (our leading cause) and Hepatitis A. 

Studies have shown handwashing involves more than just the simple act of doing it.  Good handwashing is multi-dimensional.  Food workers need positive influences on handwashing in the restaurant environment.  Factors that positively promote handwashing are kitchen and handsink design, location of well equipped handsinks, education and training, proactive health department and inspectors, customer influence, positive reinforcement from managers, development of good handwashing habits, and personal beliefs and attitudes of the food workers. 

Other elements of handwashing include using the right soap, hand antiseptic or sanitizer, and a nailbrush or friction on the fingertips using the “claw paw.”  That means bending your fingertips into the opposite palm and scrubbing with friction when you wash.  The fingertips are the vehicle for 80-90% of the microorganisms on your hands that can cause foodborne illness.  Hands-free type dispensers for soap and paper towels are also a good thing with a back-up so they are never empty.  For more information on this, go to the website for Handwashingforlife at www.handwashingforlife.com. 

3. No Bare Hand Contact with Ready-to-eat Foods – For over 10 years, the FDA Food Code has also required NO bare hand contact with ready-to-eat foods.  Most states in the U.S. have adopted that controversial part of the regulation, but it has taken awhile to show the outbreak evidence from organisms like Norovirus.   That means we need to use utensils, paper wraps, single-use gloves, or multiple barriers to handling ready-to-eat foods.  Glove use has been at the center of the controversy.  In favor of barrier usage, there are statistics on thousands of foodborne outbreaks associated with bare hand contact, but very few from the use of gloves even though their use can be abused.

 The Links – The food safety science has shown the link between infected food workers, poor hand hygiene and contaminated ready-to-eat foods.  Infected food employees are the source of contamination in approximately one in five foodborne disease outbreaks reported in the United States with a bacterial or viral cause. (1) Additional barriers are the third part of the intervention equation for interrupting the transmission of foodborne disease. 

The Best Quote on No Bare Hands -- One of my favorite quotes about bare hands was from a PhD. microbiologist who studies foodborne viruses and believes in the 3 interventions above including handwashing with use of multiple barriers.  The essence of it was “Food service companies and chains spend multi-millions of dollars on building a brand name that customers trust for food safety.  It makes no sense to risk it all to save a few cents at the very last step before the food goes to the customer with bare hands of a food worker not using an additional barrier such as a utensil or glove. ” 

Bottom Line:  These three interdependent critical factors in reducing foodborne illness transmitted through the fecal-oral route identified by NACMCF are so important to food safety.  Each of the interventions is inadequate when utilized independently and may not be effective. However, when all three factors are combined and utilized properly, the transmission of fecal-oral pathogens can be controlled. 

Additional note:  This is my last “Letter from Lacie” as my retirement has arrived! Huge thanks to you, the readers, for the helpful comments over the last several years.  Safety Management Services will carry on providing top-notch food safety education to our customers.    

(1)  Based on CDC Summary Surveillance for Foodborne-Disease Outbreaks – United States, 1988-1992 and New York 

State Department of Health data 1980-1991 published: Weingold, Guzewich, Fudala, 1994, Use of Foodborne

Disease Data for HACCP Risk Assessment. J. Food Prot. 53: 820-830.