Environmental Health
Specialists Network
Environment
E H S - Net
Host
Agent
Dave Reimann and Karen Everstine
EHS-Net
EHS-Net is the primary research program of CDC
Environmental Health Services Branch in the
National Center for Environmental Health. The
network is comprised of epidemiologists,
environmental health professionals and
laboratorians who work to understand
environmental causes of food and waterborne
diseases and to improve environmental public
health practice.
EHS-Net, organized in 2000, is a
collaborative project of CDC.
 FDA and USDA, have been active partners. They
have helped develop studies, providing guidance
and technical assistance.
 In 2006, EHS-Net expanded its focus on food
safety to include drinking-water safety; U.S.
EPA joined as another federal partner.
 Nine states are currently part of EHS-Net Food.
EHS-Net States
FBI Investigations  Inspections
Outbreak Cause
Code Violations
Contributing
Factors
Contributing Factors
Contamination Factors
C6 – Contaminated raw
product (food was
intended to be consumed
after a kill step)
C9 – Cross-contamination
of ingredients
C12 – Contamination by
a food handler who is
suspected of being
infectious
Proliferation Factors
P3 – Improper adherence
to a plan to use Time as a
Public Health Control
P7 – Improper hot-holding
due to malfunctioning
equipment
P8 – Improper or slow
cooling
Survival Factors
S1 – Insufficient
time/temp during
initial cooking or
processing
S4 – Insufficient
use of chemical
processes designed
for pathogen
destruction
Environmental Antecedents
Circumstances in place which allow a
contributing factor to occur
 People
 Process
 Economic
 Equipment
 Others?
Food Service as a System
(systems within a system)
Environment
Antecedents - “Why”
Outbreak
Contamination
C1
C2
C3
C4
C5
Handling After
Kill Step
C10
C11
C12
How it happens
No Sick Leave
Afraid of Reporting
No Policy
No Supervision
Lack of Knowledge
No Kill Step
Multiple Steps
Involving Handling
Hands Not Washed
No Gloves
Process
People
Minimum Wage
Equipment Costs
Glove Costs
Economics
Food
Hand Wash Sinks
Location of HW Sinks
Supplies for HW Sinks
Water Available
Gloves Available
Equipment
Why it happens
Cook Potatoes
Expects long hours &
hours change or cut
frequently
Regulatory oversight is not
systems oriented
Cut Potatoes
Managing food safety
is not a high priority
Poor employee
attitude
Assign double and
triple duties to
supervisor
Cool Potatoes
Low motivation
levels
No time to
supervise
No food safety
training
Store Potatoes
Little
supervision
Cook Pasta
Food contact surfaces
not sanitized
Little knowledge
of food safety
No hand washing
Store Pasta
Contributing Factors
“The What”
Direct hand
contact
Hires low
socioeconomic & low
education level
Antecedents
“The Why”
Drain
Cool Pasta
Owners beliefs
& attitude
Employees working
when ill
No sick leave
Need to work
Mix Potatoes
& Dressing
Employee beliefs & culture
Mix Pasta &
Dressing
Portion Salads
Mix Dressing
Weigh &
Adjust
Seal
Cool & Store
Cut Meats
Cut Veggies
Portion
Veggies
Add Dressing
Box
Purpose of EHS-Net Studies
 Better describe the food safety system
 Understand the relationships between
contributing factors and the antecedents
 Identify previously unrecognized antecedents
 Determine the risk associated with the
occurrence of antecedents
Ongoing EHS-Net Studies
•
Ground Beef Handling Study
•
Chicken Handling Study
•
Ill Food Worker Study
•
Microwave Oven Use Study
•
Ground Beef Grinding Logs Study
•
Cooling Study
•
Food Allergens Study
•
Kitchen Manager Knowledge (Food Manager
Certification) Study
•
Outbreak Study
http://www.cdc.gov/nceh/ehs/EHSNet/highlights.htm
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
• Convenience sample of 153 restaurants in 13
metro areas (7 states) in 2002
• On-site interview with restaurant manager or
employee
• Limited observational assessment
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Cooked to correct
temperature, but
improperly refrigerated
Prevalence of High-Risk Egg-Preparation
Practices in Restaurants That Prepare Breakfast
Egg Entrées: An EHS-Net Study
Properly refrigerated but
undercooked
Tomato Handling Practices in Restaurants
•Randomly selected restaurants in eight states
•Approximately 50 restaurants surveyed in each state in 2006
•Data collection consisted of:
•Manager interview
•Restaurant worker interviews
•Observation of raw fresh tomato receiving, storage,
holding, washing, and cutting
Tomato Handling Practices in Restaurants
Results - Managers’ perceptions of foodborne illness risk
associated with improperly prepared tomatoes:
•Tomatoes perceived as less risky than friend chicken,
smoked fish, roast beef, roast pork, and green onions
•Tomatoes perceived as more risky than cut lettuce, French
bread, and baked potatoes
•Tomatoes perceived as equally as risky as fresh berries and
cut melons
Tomato Handling Practices in Restaurants
Types of tomatoes served in surveyed restaurants:
•Round – 89%
•Grape/cherry – 29%
•Roma – 18%
•Pre-cut – 6%
Tomato Handling Practices in Restaurants
Uses of tomatoes served in surveyed restaurants:
•Salads – 89%
•Sandwiches – 80%
•Hamburgers – 52%
•Wraps – 34%
•Salsa – 16%
Tomato Handling Practices in Restaurants
•86% of managers reported that foodworkers
received training on produce handling
•50% reported a separate produce-preparation area
•74% reported that single-use gloves were used
during tomato preparation
Tomato Handling Practices in Restaurants
•Tomato washing: 82% of observations involved
rinsing tomatoes; 18% involved soaking
•Tomato washing: In 21% of soaking observations,
the water was not at least 10°F warmer than the
tomatoes
•Tomato prep: Single-use gloves observed in 64%
of tomato cutting observations
EHS-Net Outbreak Study
Questions?