The Virus Challenge

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The Virus Challenge
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CDC Estimated of Total Foodborne Illnesses,
Hospitalizations, and Deaths
Data from Mead, et.al., Food Related Illness and
Death in the United States, Emerging Infectious
Disease, 1999. Vol.5, No. 5, pp.38
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Factors that determine the pathogens with highest
risk of transmission

• Pathogenicity
• Ability of the organism to cause disease
• Virulence factors
• The factors that allow the organism to make
  someone sick
• Communicability
• Ease of spread
• Epidemiology
• The data we have to show transmission from food
  outbreaks etc.
• Other
• CDC List of Infectious Communicable Diseases

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Combination of High Levels Shed in the Feces and
Low Infectious Dose

• Adds up to create a highly infectious
  microorganism
• All listed Food Code pathogens are highly
  infectious fecal-oral route pathogens

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Characteristics of the BIG FIVE Pathogens
Listed in the Code
Source CDC
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All Food Code Listed Pathogens Have an Extremely
Low Infectious Dose

• Hepatitis A virus 10 or less viral particles
• Norovirus 10 to 100 viral particles
• EHEC is as low as 10 bacterial cells
• Shigella spp. can be as low as 10 bacterial cells
• S. Typhi is considered low for bacteria 1000
  bacterial cells

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Potential Contamination Level per Gram of Feces

• Hepatitis A (HAV) 108 viral particles
• Noroviruses (NoV) 107 viral particles
• Bacterial infections 106

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THE BIG FIVE PATHOGENS listed in the Food Code

• Norovirus
• Salmonella Typhi
• Hepatitis A Virus
• Shigella spp.
• Enterohemorrhagic or Shiga toxin-producing E.coli

Source CDC
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Norovirus
Serves as a great example of a highly infectious
microorganism
Bar 50 nanometers
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Transmission of Norovirus

• Fecal-Oral Route Primary route responsible for
  causing foodborne outbreaks
• Airborne Inhalation of microscopic droplets
  Aerosols enhance dissemination of NoV in the
  environment during an outbreak has been
  important means of transmitting NoV to staff
• Person-to-Person Important means of sustaining
  spreading an outbreak
• Environment-to-Person Important means of
  sustaining spreading an outbreak

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Potential Transmission LevelNorovirus

• Shed in the feces at levels up to 10,000,000
  viral particles per gram of feces.
• One projectile vomiting incident can potentially
  contaminate the environment with 30,000,000 viral
  particles.
• Infectious dose of NoV is estimated from 10-100
  viral particles.

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NV vs. Duke University Florida State Football
Teams---Norovirus Won

• 9/18/98, Duke Univ. football team ate turkey
  sandwiches, prepared by ill foodworker.
• 9/19/98 Duke team players - suddenly ill during
  game, with vomiting diarrhea continued to
  play
• NV crossed the line of scrimmage
• Transferred via football, players hands
• 11 FSU players became sick
• 1st documented case of person-to-person
  transmission of NV at sports event

Duke lost the game, 62-13.
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Norovirus from Prep Sink

• August 3, 1996, food worker became suddenly ill
  and vomited in the prep sink in the hotel
  kitchen.
• Sink was cleaned and disinfected with Mikro-Chlor
  sanitizing powder
• Next day sink was used to cool boiled potatoes
  for potato salad served at wedding reception
• 47 guests reported illness with vomiting
  diarrhea (attack rate 50)
• Serves as example of important role environmental
  contamination can play the difficulty in
  disinfecting contaminated environmental surfaces

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Controlling Norovirus Depends on Preventing the
Transmission

• Handwashing prohibiting bare hand contact with
  RTE food items is critical
• Removing food workers with active vomiting and/or
  diarrhea is critical
• Reducing airborne transmission, and treat as
  infectious material
• Cleaning Staff should use barriers, such as face
  masks, gloves, and aprons.
• Dispose materials used to clean-up vomiting
  incident, and thoroughly disinfect the area.

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Hepatitis A Virus

• Liver disease
• Highly Infectious
• Low Virulence
• Pathogenicity impacts adults
• Shed in feces midway through incubation period
  (1-2 weeks before symptoms appear)

Credit CDC
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Hepatitis A Virus

• Incubation period range 1550 days, Ave. 30
  days
• Symptoms More in adults than children Jaundice,
  fever, malaise, nausea, anorexia, abdominal
  pain
• Duration 1-2 wks 15 have prolonged symptoms
  6-9 mo.
• Vaccination programs in children from endemic
  areas of the U.S. are having a dramatic effect in
  reducing the national incidence of hepatitis A

Source Jim Gathany, CDC
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Symptoms of Concern

• Gastrointestinal Symptoms of Concern
• Vomiting
• Diarrhea
• Jaundice

• Other Symptoms of Concern
• Sore Throat with Fever
• Infected wound or pustular boil

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The Person in Charge
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Demonstration of Knowledge

• Based on the risks of foodborne illness
• inherent to the food operation, during
• inspections and upon request the person-in
• charge shall demonstrate to the regulatory
• authority
• - Knowledge of foodborne disease prevention
• - Application of the HACCP principles and
• - Requirements of the code.

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Assessing Demonstration of Knowledge

• Demonstration of knowledge can be satisfied
  through
• 1. Compliance with the code
• 2. Dialogue/Questions Answers or
• 3. Certified Food Safety Manager (Accredited
  Program)

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Responding Correctly to Questions

• Responding correctly to the inspectors questions
  as they relate to the specific food operation.
  The areas of knowledge include

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Questions

• (1) Describing the relationship between the
  prevention of foodborne disease and the personal
  hygiene of a food employee
• (2) Explaining the responsibility of the person
  in charge for preventing the transmission of
  foodborne disease by a food employee who has a
  disease or medical condition that may cause
  foodborne disease
• (3) Describing the symptoms associated with the
  diseases that are transmissible through food
• (4) Explaining the significance of the
  relationship between maintaining the time and
  temperature of potentially hazardous food
  (time/temperature control for safety food) and
  the prevention of foodborne illness

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Questions

• (5) Explaining the hazards involved in the
  consumption of raw or undercooked meat, poultry,
  eggs, and fish
• (6) Stating the required food temperatures and
  times for safe cooking of potentially hazardous
  food (time/temperature control for safety food)
  including meat, poultry, eggs, and fish
• (7) Stating the required temperatures and times
  for the safe refrigerated storage, hot holding,
  cooling, and reheating of potentially hazardous
  food (time/temperature control for safety food)

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Questions

• (8) Describing the relationship between the
  prevention of foodborne illness and the
  management and control of the following
• (a) Cross contamination,
• (b) Hand contact with ready-to-eat foods,
• (c) Handwashing, and
• (d) Maintaining the food establishment in
  a clean condition and in good repair
• (9) Describing foods identified as major food
  allergens and the symptoms that a major food
  allergen could cause in a sensitive individual
  who has an allergic reaction.
• (10) Explaining the relationship between food
  safety and providing equipment that is
• (a) Sufficient in number and capacity, and
• (b) Properly designed, constructed, located,
  installed, operated, maintained, and cleaned

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Questions

• (11) Explaining correct procedures for cleaning
  and sanitizing utensils and food-contact surfaces
  of equipment
• (12) Identifying the source of water used and
  measures taken to ensure that it remains
  protected from contamination such as providing
  protection from backflow and precluding the
  creation of cross connections
• (13) Identifying poisonous or toxic materials in
  the food establishment and the procedures
  necessary to ensure that they are safely stored,
  dispensed, used, and disposed of according to
  law
• (14) Identifying critical control points in the
  operation from purchasing through sale or service
  that when not controlled may contribute to the
  transmission of foodborne illness and explaining
  steps taken to ensure that the points are
  controlled in accordance with the requirements of
  this Code

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Questions

• (15) Explaining the details of how the person in
  charge and food employees comply with the HACCP
  plan if a plan is required by the law, this Code,
  or an agreement between the regulatory authority
  and the food establishment
• (16) Explaining the responsibilities, rights, and
  authorities assigned by this Code to the
• (a) Food employee,
• (b) Conditional employee,
• (c) Person in charge,
• (d) Regulatory authority and
• (17) Explaining how the person in charge, food
  employees, and conditional employees comply with
  reporting responsibilities and exclusion or
  restriction of food employees.

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Employee Health
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Employee Health

• A food employee is an individual working with
  unpackaged food, food equipment or utensils, or
  food-contact surfaces.

vs
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Main Components of Employee Health

• Responsibility of the Food Employee Manager
  Reporting Requirements
• Exclusion and Restriction guidelines
• Removal from Exclusion and Restriction

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The ApproachRisk-Based Employee Health

• Based on 4 Levels of Risk
• Removes infected food workers when most likely to
  transmit a pathogen to food items
• Balances employees needs with risk to the
  public
• Provides guidance on safely allowing infected
  employees to return to duties

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Risk-Based Employee Health

• Level I
• Active Gastrointestinal Symptoms or diagnosis
  with S. Typhi or hepatitis A virus
• Level II
• Diagnosis and symptom resolution
• Level III
• Diagnosis and never developed symptoms.
• Level IV
• Exposure to Listed Pathogen

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Summary of Food Code Exclusions

• Active gastrointestinal symptoms
• Jaundicewithin 7 days of onset
• Diarrhea,
• Vomiting
• Diagnosis with
• Norovirus diarrhea and/or vomiting,
• EHEC diarrhea and/or vomiting,
• Shigella spp. diarrhea and/or vomiting
• Diagnosis with typhoid fever
• Diagnosis with HAV
• If within 7 days of Jaundice or 14 days of any
  symptoms
• Also Exclude in a HSP
• Diagnosis with Listed Pathogen and Asymptomatic
• Sore throat with fever

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PERSONAL CLEANLINESS

• Handwashing
• Double Handwashing Removal
• Hand Antiseptic
• Fingernails
• Jewelry

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Handwashing
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Handwashing

• Every Stage of Handwashing is Important!!
• Scrubbing w/ soap 1 log virus reduction
• Rinsing hands under high water pressure volume
  of running water aids in removing transient
  viruses
• Drying hands 1 log virus reduction
• Hand dryer vs. paper towel issue

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Handwashing Elements

• Friction is the most important element in
  removing transients

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Handwashing Continued

• Handwash Time 20 seconds including scrubbing
  for 10-15 seconds
• Soap surfactant effect in removing grease, soil,
  and debris from the hands.
• Research recommends bland soap (10-15 sec.
  contact) over antimicrobial soap, if not used
  properly (15 sec. contact)
• Water Temp Soap efficacy is tested at ASTM
  Stnds (100F - 107F)
• Minimum water temp 100F

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Naked RNA Viruses HAV Noroviruses
Hand Antiseptics
Hand sanitizers, such as ethanol, isopropyl,
chlorine are highly effective against bacteria,
but only minimally to moderately effective
against Norovirus HAV

• Basic structural difference Lipid envelope
• Lipid envelope Sanitizer effect predictable
  effective
• No envelope naked virus Sanitizer not effective

• Sanitizer effect varies with
• different temps
• concentration
• disinfectant/virus volume ratio
• protein load
• serologic types

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Hand Dryer Vs Paper Towels

• Key is proper tools for type of operation
• 30 seconds required for properly drying hands
  with a hand dryer
• Paper toweling has the additional advantage of
  friction

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FingernailsNails, Trimmed Maintained
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Fingernails
Artificial
Polished
Working with exposed food polished and
artificial nails approved only if covered with
glove in good repair
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Jewelry
One Plain Ring such as a wedding band on hands.
JEWELRY PROHIBITED
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HYGIENIC PRACTICES

• Food Contamination Prevention
• Hair Restraints
• Animals

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Eating, Drinking, or Using Tobacco
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Single-Service Beverage Container
Preventing Contamination of Food Equipment Utens
ils Linens Single service items
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Beverage Containers

• Acceptability?

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Summary

• The key to Implementation of Employee Health is
  Communication
• New Tools are provided in the Food Code Annex to
  enhance Communication
• Successful implementation requires all food
  safety personnel working together as a team
• including food safety professionals from
  academia, Industry and regulatory programs.
• Successful implementation can have an impact in
  reducing NoV and other FBI spread by contaminated
  food workers

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Summary

• Multiple ways used to protect public health
• Employee health
• Handwashing
• No bare hand contact with ready-to-eat foods
• New focus is based on new science regarding the
  agents that are most likely to be transmitted
  from a sick food worker via food.
• Norovirus
• Hepatitis A virus
• S. typhi
• Shigella
• E.coli O157H7 or other EHEC
• Success will be dependent on raising awareness
  and education