Risk Control Services : from Liberty Mutual Insurance
Foodborne Illnesses
Highlights:
• Foodborne illness is a major
public health issue
• More than a quarter of the
American population is affected
• In most of the cases (81%), the
food pathogen is never identified
• Basic food safety: steps you can
take
• Bacteria and Virus: as a cause of
foodborne illness
Foodborne illness is a major public health issue. According to 2011
estimates from the Centers for Disease Control (CDC), the total
annual burden of foodborne illness in the United States is estimated
at 48,000,000 illnesses, roughly one out of six Americans.1
Of these, there are 128,000 hospitalizations and 3,000 deaths. The CDC’s
“Surveillance for Foodborne-Disease Outbreaks – United States,” report for 19931997 identifies the most significant contributing factors to foodborne illness.
Five of the broad categories of contributing factors directly relate to food safety
concerns within retail and food service establishments and are collectively termed
by the FDA as “foodborne illness risk factors.” The five categories are: food from
unsafe sources, inadequate cooking, improper holding temperatures, contaminated
equipment, and poor personal hygiene. 2
In most of the illnesses (80%) the pathogen was not determined.1 However, there are
many known pathogens and the more likely agents of foodborne illness are listed
below. The implementation of a program focused on good personal hygiene and
control of viruses and bacteria through cooking and other means can dramatically
reduce the risk of disease.
A successful control program for foodborne illness, whether in the food processing
or food service industry, starts with analyzing operations and processes to identify
sources of contamination and pathogen growth. Many risks can be averted using
Good Management Practices (GMPs) and Standard Sanitary Operating Practices
(SSOPs). The more significant points of pathogen control are addressed in the
Hazard Analysis and Critical Control Point (HACCP) plan. This reference note will
not go into HACCP details but there is the understanding that most companies
processing food will have implemented HACCP, in some cases by mandate of the
FDA, the USDA and local codes. Food service operations do not typically have
HACCP plans in place. In some jurisdictions, for example some counties in Maryland,
food servers must implement HACCP, but it is not commonly practiced in its full form
due to the complexity of applying it to large and changing menus.
This reference note may be used in the hazard analysis to estimate the potential
hazard severity, formalize intervention programs, and develop material for employee
training.
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© 2013 Liberty Mutual Insurance – All Rights Reserved January 2012
Basic Food Safety
Hand Cleanliness
Hands are most exposed to microbes because they are our primary means of contact and
manipulation. Some diseases are spread when disease-causing microbes on a person’s hands get
into food that he or she touches. It is also very likely that when one individual with contaminated hands
touches an object, such as a table, and someone else contacts the table, they then become exposed
and can transfer the pathogen to their food. When the food is eaten by the consumer or restaurant
patron, microbes enter the body and cause foodborne illness.
Thorough hand washing with hot, soapy water prevents bacteria and viruses from transferring from
hands to foods. Frequently changing hand coverings also dramatically reduces the likelihood of virus
and bacteria transfer. Many organizations provide ethanol-based hand sanitizers to their employees.
Unfortunately, the more problematic viruses are not killed by ethanol, so cleaning hands with soapy
water and thoroughly drying with clean towels is essential.
Hygiene Precautions
• Wash hands for at least 20 seconds under clean running warm water. Apply an amount of cleaning
product as recommended by the manufacturer. Rub hands together vigorously for at least 10 to
15 seconds. 2 Thoroughly scrub hands, wrists, fingernails and between fingers. Hot water that is
comfortable for washing hands is not hot enough to kill bacteria. Body oils on hands hold soils
and bacteria, so hot or warm soapy water is more effective than cold soapy water at removing
those oily soils and the bacteria in them. Rinse thoroughly under clean running warm water. 2
• Wash hands before and after preparing food, and especially after
preparing raw meat, poultry, eggs and seafood.
• Wash hands after using the bathroom, changing diapers, handling pets or whenever you have
touched something that may be contaminated. This is the primary source of virus transfer.
• Dry hands with a clean towel or use durable, disposable paper towels so germs are thrown
away. Air drying is an alternative but the friction action of the towel makes hands cleaner.
• Food preparers should use gloves to prevent bare hand
contact when handling any ready-to-eat foods.
• Food preparers who are ill should not handle food with bare hands. Illness
should be reported to management for a determination as to whether
to reassign the employee or let them have some time off.
• Do not reuse knives, utensils, pans, bowls, cutting boards, etc., especially after
they have been exposed to raw foods of animal origin such as meat, eggs and
shellfish. Consider color-coding these items to avoid cross contamination.
• Discard leftovers or refrigerate them promptly.
• All wiping cloths should be stored in an approved sanitizing solution, usually a chlorine
solution of 50 – 100 PPM, or about a tablespoon of household bleach per gallon of water.
Temperature Abuse
Small changes in temperature dramatically affect microbiological growth. Consequently, it is vital
to manage the “cold chain,” meaning that perishable goods must be refrigerated throughout the
long journey from farm to fork. For food servers, supermarkets, convenience stores and other food
retailers, there must be a program in place to verify that the perishable foods are being delivered at
the right temperature and that there were no temperature abuse events in transit from the distributor.
The temperature of all goods must be checked. If warmer than specifications, a decision will have
to be made as to whether to accept or reject the items. Once received, all perishables should be
refrigerated at the correct temperature. Storage should allow for refrigerated air circulation and
consideration given to using temperature loggers and alarms for refrigeration units.
Intermittently adding warm moist air into cold refrigeration units can allow moisture to condense. This
moisture can allow mold to grow on refrigeration structures. If not removed, mold can amplify and
pose a health hazard, if ingested or inhaled. Care needs to be taken to prevent such condensation
and mold growth. If mold is visible, it needs to be safely removed to prevent food contamination.
Microbes
One must assume that bacteria are always present. When we ingest bacteria, whether we become
ill or not, is based on many factors, the most important of which are the type of microbe (bacteria
or virus) and the number present. A food may be fine for consumption even with bacteria present.
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However, if the food is left out too long, the bacteria can multiply exponentially and quickly become a
risk. Viruses do not multiply outside a living host but they do multiply once ingested.
Microbes are killed by heat. Heating food to an internal temperature above 185ºF, for even a few
seconds, is sufficient to kill bacteria, viruses and parasites.
Bacteria as a Cause of Foodborne Illness
Bacteria are single cell organisms that can reproduce at an exponential rate. Under ideal conditions
a single cell can reproduce in 5 hours to over 1 million cells, and to over 10 billion in 24 hours. Ideal
conditions include warmth, moisture and neutral pH. Estimates are that 3,600,000 foodborne illnesses
occur from bacteria annually, with about 1,000 being fatal.3
Campylobacter
What is it and where does it come from?
Campylobacter is a bacteria. About 70% of campybacteriosis cases are from chicken consumption.
A study by the USDA demonstrated that up to 88% of broiler chicken carcasses have the bacteria.
Other food sources of campylobacter include shellfish, mushrooms, unpasteurized milk, eggs and
undercooked meat, including hamburger and pork.
What does it do to you?
With an incubation period for the bacteria of two to five days, diarrhea is the most common symptom.
Other symptoms include nausea, fever, vomiting and abdominal pain. Although most cases are mild,
this illness can be severe and life threatening, especially if another illness is present such as cancer,
liver disease or AIDS. In rare cases a person can be diagnosed with Guillain Barre disease which is
characterized by general paralysis lasting weeks or even months.
How likely is it?
This accounts for 9% foodborne illnesses.4 An estimate of the number of cases, is 845,000 annually,
with 76 deaths occurring annually.1
How do you control it?
• The single most important control for this foodborne illness is to thoroughly cook all
poultry products. The thickest part of the bird should be heated to at least 180ºF.
• Keep meat and poultry refrigerated until cooking time. Thaw meat and poultry in the refrigerator.
• Do not leave cooked food out longer than two hours.
• Wash hands and utensils thoroughly using soap and water.
• Thoroughly wash all fruits and vegetables.
• Try to eliminate fruit skins from recipes.
Salmonella
What is it and where does it come from?
Salmonella is a type of bacteria that causes intestinal infection and occasionally typhoid fever.
Salmonella can be found it the intestines of birds, reptiles and mammals and is also associated with
seafood, raw seed sprouts, raw vegetables, raw milk and unpasteurized juice. 2
What does it do to you?
Symptoms of salmonella are fever, cramps, diarrhea and nausea, usually occurring within 6 to 72
hours.
How likely is it?
Salmonella is the most common foodborne illness from bacteria in the U.S. Nontyphoidal salmonella
accounts for 11% of illnesses and 28% of all food-related deaths.4 Over 1,020,000 cases are
estimated annually.1
How do you control it?
• Do not serve foods with uncooked eggs.
• Thoroughly cook ground beef, poultry and eggs before serving.
• Thoroughly wash work surfaces, utensils and hands after exposure to meat and poultry products.
• Do not handle Ready-to-eat foods with bare hands. 2
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E. Coli
What is it and where does it come from?
E. coli is a contraction for Escherichia coli, a bacteria found in the lower intestinal tract of humans and
animals. There are many types of E. coli bacteria; some are vital to health while others can cause
infection or produce toxins. The strain that has had the most serious consequences is E. coli 0157.
The main source is the bovine intestine; consequently beef products should be a primary concern. E.
coli has also been found in the intestines of chicken, pigs, goats, deer and sheep. Unwashed produce,
which may have been exposed to organic fertilizer, can also carry the E. coli bacteria.
Meat ordinarily becomes contaminated with the E. coli bacteria in the slaughterhouse when intestinal
contents are allowed to come in contact with the carcass. When the meat is ground into hamburger,
E. coli can be mixed throughout the ground beef. This is why it is so important to heat ground beef
thoroughly.
Milk becomes contaminated through the cow udders, despite the use of bactericide during milking.
What does it do to you?
E. coli travels through the stomach and small intestine and then attaches to the large intestine where
it creates toxins that result in inflammation. Following an incubation period of one to nine days3,
symptoms begin with abdominal pain and severe cramps. The most common symptoms are mild
and bloody diarrhea. At the most severe level the illness can be fatal. Fatal illness is more likely in
the elderly and those under five years of age and is a result of low red blood cell count and kidney
damage.
How likely is it?
Studies indicate that the prevalence of E. coli 0157 is about 3,000 hospitalizations and 30 deaths
annually.4
How do you control it?
• The primary controls are:
•
Thorough cooking of raw meat to a core temperature of 155ºF for at least 15 seconds
•
Pasteurizing milk
•
Avoiding cross contamination
• Keep raw meat separate from ready-to-eat foods.
• Store raw meat where there can be no dripping on foods below.
• Thoroughly wash hands and any surfaces and utensils, including meat
thermometers that come in contact with raw or partially cooked meat.
• Wash hands thoroughly after using bathrooms.
• Serve only pasteurized milk, juice and cider.
• Wash fruits and vegetables thoroughly.
• Do not handle ready-to-eat foods with bare hands. 2
Listeria
What is it and where does it come from?
Listeria is a bacteria that causes an illness called listeriosis. It is ubiquitous in the environment, with
contamination coming from a wide range of sources. It can be found in soil, wastewater, animals,
insects, birds and vegetation. It can live in the intestines of birds, animals and humans for long periods
of time. Listeria is also one of the few foodborne bacteria that can grow at refrigerator temperatures.
What does it do to you?
Unlike many of the other foodborne bacteria which attach to the intestinal wall, listeria passes into
the blood stream and can infect cells throughout the body. Symptoms of listeriosis include muscle
aches, fever, diarrhea and abdominal pain. Infection may also spread to the nervous system causing
headaches, stiff neck, loss of balance or convulsions. If it spreads to the brain, stroke-like symptoms
can result. Listeria has even been associated with the development of meningitis and encephalitis,
which are infections of the brain.
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How likely is it?
Listeria is relatively uncommon, causing about 1,500 hospitalizations annually and about 250 deaths.
This means that about one in six cases are fatal.1
How do you control it?
• Store ready-to-eat foods (luncheon meats, cold cuts and soft
cheeses) at 40ºF or lower and date mark them. 2
• Clean refrigerators frequently.
• Cook leftover foods and ready-to-eat foods (hot dogs or sausage) until steaming hot.
• Cook poultry thoroughly.
• At-risk individuals should avoid uncooked fish such as sushi or smoked trout.
Virus as a Cause of Foodborne Illness
Viruses are different from bacteria. They must live off living host cells. Since food products are dead,
food is only a carrier, not a breeder of viruses. Viruses are generally spread from person to food to
person, with transmission to the food taking place through handling, sneezing or coughing.
Foodborne illnesses from viruses number approximately 5,500,000 annually, with about 150 being
fatal. More foodborne illnesses result from viral exposure than bacterial exposure, but the number of
fatal illnesses is significantly less.4
Norovirus or Norwalk-like Virus
What is it and where does it come from?
This is the most common cause of foodborne illness that is usually spread by a food preparer who
transmits the virus from his hands to the food. This is an enteric virus, meaning that it is spread fecal
to oral. Sometimes the virus is transferred to an inanimate object (technically called a fomite) from
which someone else contacts the virus. Oyster fishermen have even contaminated oysters while
harvesting them.
What does it do to you?
This virus causes severe vomiting and diarrhea. It usually resolves in two days.
How likely is it?
This is the most likely type of foodborne illness. Annual cases are estimated at 5,500,0001 with about
150 being fatal.1
How do you control it?
• Food handlers should not work when ill.
• Food handlers should always wash their hands thoroughly
with soap and water after using the bathroom.
• Cooking foods to a temperature of 185ºF will kill the virus.
Hepatitis A Virus
What is it and where does it come from?
Hepatitis A Virus (HAV) is one of five types of hepatitis. It is caused by a virus that infects the liver and
compromises its function. It is spread from infected human to human via indirect fecal to oral route.
This most commonly occurs because individuals who are preparing food fail to adequately cleanse
their hands after using the bathroom.
It can also be spread by contaminated water and raw foods. Studies have found the hepatitis virus in
shared popcorn and bowls of food.
What does it do to you?
HAV causes flu-like symptoms including headache, malaise, muscle ache, nausea, loss of appetite
and jaundice, with the onset of symptoms occurring about a month after exposure. The severity of
illness increases with age and some individuals are at risk of death.
How likely is it?
A conservative estimate is that 1,500 cases occur annually in the U.S., with about seven deaths.4
How do you control it?
• Food handlers should not work when ill.
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• Food handlers should always wash their hands thoroughly
with soap and water after using the bathroom.
• Cooking foods to a temperature of 185ºF will kill the virus.
Mold as a Cause of Foodborne Illness
What is it and where does it come from?
Mold is a fungus that is always present. Mold spores come from outside air or dirt that is brought
indoors. Mold spores that are normally present in the air “look” for moist, organic environments to
grow. Moist structures inside a refrigeration unit provide such an environment.
What does it do to you?
The main effect of mold is allergy symptoms. Since people’s sensitivity to mold spores vary, some
may have a strong reaction while others may not be affected at all.
How likely is it?
Since individual sensitivity varies, it is hard to estimate the resulting health effect. The best plan is to
prevent mold growth and to remove it safely.
How do you control it?
• Prevent water intrusions.
• Keep the introduction of warm, moist air into the refrigeration unit at a minimum.
• Food handlers should always wash their hands thoroughly
with soap and water after using the bathroom.
• If present, use safe removal procedures such as given in the Guidelines
on Assessment and Remediation of Fungi in Indoor Environments as given
by the New York City Department of Health & Mental Hygiene.
Parasite as a Cause of Foodborne Illness
Toxoplasma Gondii
What is it and where does it come from?
Toxoplasma gondii is a parasite found in raw and undercooked meat (especially pork, lamb and deer
meat), unwashed fruits and vegetables, water, dust, soil, dirty cat-litter boxes, and outdoor places
where cat feces can be found.3
What does it do to you?
Toxoplasma gondii causes a flu-like illness that usually appears 5 to 23 days after eating the infected
food and may last for months. Those with a weakened immune system may develop more serious
illness. Can cause pregnancy problems, including miscarriage.6
How likely is it?
According to the CDC, Toxoplasma Gondii causes about 4,400 hospitalizations and 300 deaths each
year. It is the second most common foodborne illness resulting in death.1
How do you control it?
• Wash hands before handling food.
• Cook meats thoroughly.
Food Allergens as Food Safety Hazards
According to the FDA, over 11 million Americans suffer from one or more food allergies. A foodallergic response is commonly characterized by hives or other itchy rashes, nausea, abdominal pain,
vomiting and/or diarrhea, wheezing, shortness of breath, and swelling of various parts of the body. In
severe cases, anaphylactic shock and death may result.4
Each year in the U.S., it is estimated that anaphylaxis to food results in 30,000 emergency room visits,
2,000 hospitalizations and 150 deaths.5 In order to prevent the occurrence of food allergic reactions,
product labels must inform the customer of the presence of allergenic ingredients and procedures
must be implemented to prevent cross-contamination during food processing and preparation.
According to the FDA the following foods can cause a serious allergic reaction in sensitive individuals
and account for 90% or more of all food allergies:2
• Milk
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• Egg
• Fish (such as bass, flounder, or cod)
• Crustacean shellfish (such as crab, lobster, or shrimp)
• Tree nuts (such as almonds, pecans, or walnuts)
• Wheat
• Peanuts
• Soybeans
The Food Allergen Labeling and Consumer Protection Act (FALCPA) was signed in 2004 and applies
to all foods regulated by the FDA. Unless the food source of a major food allergen is part of the
ingredient’s common name or is already identified in the ingredient list, it must be included in one of
two ways:
1. In parentheses following the name of the ingredient. For example: “lecithin (soy),” “flour (wheat),”
and “whey (milk)”
2. Immediately after or next to the list of ingredients in a “contains” statement. For example:
“Contains Wheat, Milk and Soy”5.
The 2008 Conference of Food Protection (CFP) passed Issue 2008-III-006 stating that food allergy
awareness should be a food safety training duty of the Person in Charge.5
Summary
Regardless of the various illnesses that can be contracted through contaminated foods, it is most
important to focus control efforts on the basics: hygiene, cleanliness, refrigeration, cooking, storage
and handling. Avenues to introduce contamination must be identified and controlled. Opportunities to
stop the growth or kill pathogens and prevent cross-contamination should be taken where possible.
Those who are in a position to handle or process food should be highly knowledgeable about critical
control points and the methods and procedures required to reduce the risk of foodborne illness.
References
1. CDC Estimates of Foodborne Illness in the United States – CDC 2011 Estimates, February 2011.
2. U.S. Food and Drug Administration, Food Code, 2009.
3. U.S Department of Agriculture, Kitchen Companion: Your Safe Food Handbook. (http://www.fsis.usda.gov/PDF/Kitchen_
Companion.pdf
4. Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson M-A, Roy SL, et al., Foodborne Illness Acquired in the
United States – Major Pathogens, Emerging Infectious Diseases Journal, 2011 January. (Online publication ahead of
print). http://www.cdc.gov/EID/content/17/1/pdfs/09-1101p1.pdf
5. Federal Food Allergy Education Strategies. (http://www.fsis.usda.gov/PDF/Atlanta2010/Slides_FSEC_JSneed_Allergy.pdf
6. CDC Toxoplasma Infection and Animals. (http://www.cdc.gov/healthypets/diseases/toxopasmosis.htm
Additional Resources
Liberty Mutual Insurance Risk Control references:
• Safe Cooking and Handling Temperatures, RC 6211
• Fungi and Mold in Indoor Environments, RC 6106
• Remediation of Mold From Both Clean Water and Flood Water Contamination in Buildings, RC 5428
New York City Department of Health and Mental Hygiene, Guidelines on Assessment and Remediation of Fungi in
Indoor Environments. http://www.nyc.gov/html/doh/html/epi/moldrpt1.shtml
The illustrations, instructions and principles contained in the material are general in scope and, to the best of our knowledge, current at the time of publication. No attempt has
been made to interpret any referenced codes, standards or regulations. Please refer to the appropriate code-, standard-, or regulation-making authority for interpretation or
clarification. Provided that you always reproduce our copyright notice and any other notice of rights, disclaimers, and limitations, and provided that no copy in whole or in part is
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© 2013 Liberty Mutual Insurance. All rights reserved.
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