An outbreak of Norwalk-like viral gastroenteritis in a frequently penalized food service operation: A case for mandatory training of food handlers in safety and hygiene. (Features).Introduction In the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , known pathogens account for an estimated 38.6 million food-related illnesses each year, of which 23 million (60 percent) are attributable to infection by Norwalk-like viruses (NLVs) (Mead et al., 1999). Norwalk-like viruses caused approximately 96 percent of the nonbacterial gastroenteritis gastroenteritis: see enteritis. gastroenteritis Acute infectious syndrome of the stomach lining and intestines. Symptoms include diarrhea, vomiting, and abdominal cramps. outbreaks reported to 33 state health departments from January 1996 to June 1997, and eating at restaurants or at events with catered meals accounted for 26 percent of these outbreaks (Frankhauser, Noel, Monroe, Ando, & Glass, 1998). The re-emergence of food-related illness in the United States is believed to be due to many factors, including more frequent dining at restaurants and inadequate food safety and hygiene knowledge among food handlers (Kaferstein, Motarjemi, & Bettcher, 1997). The mode of NLV NLV Norwalk-Like Virus NLV North Las Vegas (Nevada) NLV National Language Version NLV National Library of Vietnam NLV Nanosat Launch Vehicle NLV New Living Version (version of the Bible) transmission varies from ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth. in·ges·tion n. 1. The act of taking food and drink into the body by the mouth. 2. of contaminated contaminated, v 1. made radioactive by the addition of small quantities of radioactive material. 2. made contaminated by adding infective or radiographic materials. 3. an infective surface or object. food or water to person-to-person transmission via direct contact, aerosol, or contaminated objects (Hedherg & Osterholm, 1993). According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. a report by the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ), ingestion of potato salad by an infected food handler and person-to-person transmission were responsible for recent outbreaks of NLV in Alaska and Wisconsin, respectively (CDC, 2000). Raw oysters raw oysters food consumed as a love potion. [Popular Folklore: Misc.] See : Aphrodisiacs (Centers for Disease Control and Prevention [CDC], 1994, 1995; Kohn et al., 1995) and infected food handlers (Arness et al., 2000; Daniels et al., 2000; Kilgore et al., 1996) have been responsible for most NLV outbreaks in the United States. In December 1999, an outbreak of acute gastroenteritis occurred among people who had eaten meals at a Christmas banquet in Toledo, Ohio
Methods Epidemiological Investigation A case-control study case-control study, n an investigation employing an epidemiologic approach in which previously existing incidents of a medical condition are used in lieu of gathering new information from a randomized population. was conducted to determine the cause of the outbreak. A standard case-history reporting form was used to record demographic characteristics, the onset and symptoms of the illnesses, and the types of foods eaten by both ill people and well people. A case of gastroenteritis was defined as an illness characterized by nausea, vomiting vomiting, ejection of food and other matter from the stomach through the mouth, often preceded by nausea. The process is initiated by stimulation of the vomiting center of the brain by nerve impulses from the gastrointestinal tract or other part of the body. , or diarrhea occurring one to 96 hours after eating the meal. The controls were people who attended the dinner banquet and ate the meal but did not become sick. Of the ill people who met the case definition, 25 agreed to provide stool samples for laboratory examination. Each person received a Cary-Blair (individually packaged tube containing two sterile swabs and a non-nutrient transport media), a small sterile container, and a standard instruction leaflet explaining how to collect an uncontaminated stool sample. After collection, both bulk and Cary-Blair stool samples were placed in sealable sandwich bags and kept in refrigerated re·frig·er·ate tr.v. re·frig·er·at·ed, re·frig·er·at·ing, re·frig·er·ates 1. To cool or chill (a substance). 2. To preserve (food) by chilling. condition during storage and transportation to the health department. Of the 25 people who agreed to provide samples, 12 did so within 48 to 72 hours of the onset of gastroenteritis symptoms. Stool samples were not, however, collected from any of the food handlers. At the health department, all samples were placed in Styrofoam boxes containing dry ice and immediately transported to the Ohio Department of Health (ODH ODH Ohio Department of Health ODH Oxygen Deficiency Hazard ODH Oklahoma Department of Health ODH Off da Hook (hip hop song) OdH Octopus Dofleini Hemocyanin ODH Oracle Data Hub ) in Columbus for examination. The Cary-Blair stool samples were examined for three enteropathogenic enteropathogenic having pathogenicity for the intestine. enteropathogenic Escherichia coli strains of E. coli which cause enteritis by close association with enteric cells. Includes attaching and effacing E. coli. bacteria--Escherichia coli O157:H7, Salmonella, and Shigella--at an ODH laboratory according to ODH Standard Protocol, and the bulk stool samples were examined for NLVs with reverse transcriptase-polymerase chain reaction (RT-PCR RT-PCR reverse transcriptase-polymerase chain reaction. See PCR1. ) at a CDC laboratory in Atlanta, Georgia. Environmental Investigation The catering facility was inspected on December 8, 1999, and the manager was interviewed to determine whether food safety and hygiene violation had occurred during food preparation, storage, or serving. None of the food handlers, however, were available for interview. Food samples were not collected and examined for possible contamination with the etiologic agent. According to the manager, leftover foods from the banquet had been discarded. Results Epidemiological Investigation Of the 137 people who ate at the Christmas banquet, 93 (67.9 percent) became ill. Of those, 56 (60.2 percent) were female, and 37 (39.8 percent) were male. Eight ill people sought medical care, and one was hospitalized. The ages of ill people ranged from about two years to 74 years, with a median age of 25 years. A majority of ill people (55.5 percent) were between 15 and 39 years of age. Eighty people met the case definition for NLV-associated gastroenteritis. Of these, 80 percent had diarrhea, 77.7 percent had nausea, 62.5 percent experienced vomiting, 53.8 percent had abdominal cramps, 41.4 percent had fevers or chills, and 37.5 percent had headaches. The onset of illness was between one and 85.5 hours (median 30.8 hours) (Figure 1). The duration of the illness ranged from three days to one week. All the Cary-Blair stool samples were negative for Escherichia coli Escherichia coli (ĕsh'ərĭk`ēə kō`lī), common bacterium that normally inhabits the intestinal tracts of humans and animals, but can cause infection in other parts of the body, especially the urinary tract. 0157:H7, Salmonella, and Shigella shigella Any of the rod-shaped bacteria that make up the genus Shigella, which are normal inhabitants of the human intestinal tract and can cause dysentery, or shigellosis. Shigellae are gram-negative (see gram stain), non-spore-forming, stationary bacteria. S. (ODH communique). Eleven of the 12 bulk stool samples were, however, positive for GII-type Norwalk-like virus (CDC communique). Eating tossed salad was significantly associated with the outbreak (odds ratio [OR] = 2.5, 95 percent confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] = 1.02-6.26) (Table 1). Environmental Investigation The food was served in an on-site banquet hall Definition A banquet hall is a room used for social gatherings like receptions, reunions, parties, and business events. and included beef, fried chicken Fried chicken is chicken which is dipped in a breading mixture and then deep fried, pan fried or pressure fried. The breading seals in the juices but also absorbs the fat of the fryer, which is sometimes seen as unhealthy. , mashed potatoes n. pl. 1. Potatoes which have been boiled and mashed to a pulpy consistency, usu. with sparing addition of milk, salt, butter, or other flavoring. It is a popular accompaniment to a meat course [U.S., 1900's], providing bulk and calories to a meal. and gravy, tossed salad, condiments, rolls, butter, beverages, and dessert. The implicated im·pli·cate tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates 1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot. 2. food was received pre-packaged, but was portioned into large bowls and served along with condiments (tomatoes, cucumber, and sliced cheese) prepared at the catering facility Health inspection of the facility did not provide information as to the cause of the outbreak. In the past, however, the facility had been cited frequently for critical food safety and hygiene violations, including improper food storage temperatures, inadequate employee hand-washing practices, improper thawing of potentially hazardous foods Potentially Hazardous Food is a term used by food safety organizations to classify foods that require time-temperature control to keep them safe for human consumption. A PHF is a food that:
Discussion Previous studies have shown that infected food handlers can transmit NLVs to restaurant patrons (Arness et al., 2000; Daniels et al., 2000; Kilgore et al., 1996). Since victims can continue to shed the virus after symptoms cease, infected but recovering or non-symptomatic food handlers can transmit the virus to other persons (White et al., 1986). Although the primary source of this outbreak was unknown, that source could have been failure to follow safe food-handling practices during preparation, storage, or serving. An infected but nonsymptomatic food handler was also considered as the likely source for the virus. The fact that employees were not available for interview and did not provide stool samples as requested by health department officials gives credibility to the hypothesis that an infected food handler might have contaminated the suspect food. In February 2000, NLV outbreaks occurred among Chrysler car dealership This article is about car dealerships. For the indie pop band, see Dealership (band). A car dealership or vehicle local distribution is a business that sells new cars and/or used cars at the retail level, based on a dealership contract with an automaker or employees in 13 states. Four-sided salad was implicated in the outbreak (relative risk [RR] = 3.5, 95 percent CI = 2.3-5.2) (CDC communique). Another caterer in Toledo prepared the suspect food, which was distributed to the Chrysler car dealerships in different states. Inspectors found 57 health violations, including poor sanitation of food contact surfaces, improper food temperatures, and poor employee hygiene during post-outbreak inspection of the facility In the past, the facility also had been cited frequently for critical food safety and hygiene violations (unpublished inspection report, Toledo Health Department). During post-outbreak interviewing of employees by health officials, none of the employees of this catering facility indicated having recent symptoms of gastroenteritis. Two out of 15 employees tested by serological serological pertaining to or emanating from serology. serological test one involving examination of blood serum usually for antibody. means did, however, have positive titers for NLVs (CDC communique). Some studies have shown that restaurants with poor inspection scores are more likely to contribute to disease outbreaks than restaurants with good inspection scores (Irwin, Ballard, Gordon, & Kobayashi, 1989; Luby, Jones, & Horan, 1993), and that training of restaurant personnel in food safety and hygiene could reduce health violations and minimize risks of foodborne outbreaks (Cotterchio, Gunn, Coffill, Tomey & Barry, 1998; Tebutt & Southwell, 1989). The state of Ohio food code allows exemption from one standard inspection per year for high-risk food service operations with personnel certified in food safety and hygiene by a recognized training agency. None of the food handlers at either catering facility discussed above had such a certificate before the outbreak (Toledo Health Department, unpublished report). Examination of the 1998-1999 food service inspection records of the Toledo Health Department indicated that restaurants without certified personnel and food handlers received more citations for food safety and hygiene violations than restaurants with certified personnel, and that 97 percent of the restaurants without trained personnel had one or more critical violations, while only three percent of the restaurants with trained personnel had such violations. In a study conducted to determine if training of food handlers in food safety and hygiene could reduce health violations, Kassa et al. (2001) found that in Toledo, restaurants with trained personnel received significantly better inspection reports than restaurants without trained personnel. Kassa et al. (2001) evaluated the inspection reports for 70 of 350 high-risk food service operations and rated each food service operation on a scale of 1 (very poor) to 5 (very good). Of the 70 food service operations, 26 had at least one staff member trained in food safety and hygiene, while 44 did not have any personnel so trained. The mean inspection score for food service operations with trained personnel was 3.58 [+ or -] 0.95, while that for food service operations without trained personnel was 2.77 [+ or -] 0.91; the means for the two groups were significantly different from each other (p < .01). The study clearly demonstrated that training of personnel in food safety and hygiene would minimize health violations. Food service operations with few or no health violations are less likely to contribute to foodborne outbreaks (Irwin, Ballard, Gordon, & Kobayashi, 1989; Luby, Jones, & Horan, 1993). Conclusion and Recommendation Foodborne outbreaks are likely to occur in food service operations with chronic health violations. The catering facilities responsible for the NLV outbreaks discussed in this paper had been cited frequently by health officials for critical food safety violations. The frequency of the violations may have been due in part to the lack of properly trained personnel and food handlers that was also remarked at the time the outbreaks occurred. Training of personnel/food handlers in food safety and hygiene may be necessary for reducing health violations and preventing the occurrence of foodborne outbreaks. Corresponding Author: Hailu Kassa, Associate Professor, 224 College of Health and Human Services Noun 1. Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Department of Health and Human Services, HHS , Bowling Green State University Bowling Green State University, at Bowling Green, Ohio; coeducational; chartered 1910 as a normal school, opened 1914. It became a college in 1929, a university in 1935. Bowling Green Bowling Green. 1 City (1990 pop. 40,641), seat of Warren co., S Ky., on the Barren River; inc. 1812. It is a shipping and marketing center for an area producing tobacco, corn, livestock, and dairy items. , OH 43403-0280. E-mail: <hkassa@hgnet.bgsu.edu>. [Graph omitted]
TABLE 1
Types of Food Served and the Likelihood That People Who Became
III Had Eaten Them
Food Item Odds 95% Confidence p-Value
Ratio Interval
Sliced beef 1.4 0.55-3.26 0.60
Fried chicken 2.0 0.75-5.05 0.19
Mashed potatoes 2.4 0.35-15.92 0.55
Chicken gravy 1.3 0.48-3.26 0.78
Beef gravy 1.0 0.40-2.45 0.85
Vetgetables 1.3 0.54-3.29 0.62
Tossed salad 2.5 1.02-6.28 (a) 0.43
French salad dressing 0.9 0.28-3.07 0.91
Ranch salad dressing 2.2 0.72-6.78 0.20
Italian salad dressing 2.3 0.43-16.54 0.50
Blue cheese dressing 1.1 0.17-8.64 1.00
Rolls 1.5 0.55-4.18 0.51
Butter 1.2 0.47-3.06 0.85
Dessert 2.0 0.81-4.99 0.14
Ice 2.1 0.57-7.72 0.34
Water 0.7 0.19-2.75 0.80
Pop 1.7 0.50-5.59 0.50
Juice 0.3 0.06-1.40 0.12
(a)A 95% confidence interal is significant.
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The Journal also regularly publishes authoritative editorials and commentaries and serves as a forum for the analysis of health policy. , 79(5), 586-590. Kaferstein, EK., Motarjemi, Y., & Bettcher, D.W (1997). Foodborne disease control: A transnational challenge. Emerging Infectious Diseases, 13(4), 503-510. Kassa, H.K., Harrington, B., Bisesi, M., & Khuder, S. (2001). Comparisons of microbiological evaluation of selected kitchen areas with visual evaluation for preventing potential risk of foodborne outbreaks in food service operations. Journal of Food Protection, 64(4), 509-513. Kilgore, P.E., Belay be·lay v. be·layed, be·lay·ing, be·lays v.tr. 1. Nautical To secure or make fast (a rope, for example) by winding on a cleat or pin. 2. , E.D., Hamlin, D.M., Noel, J.S., Humphrey C.D., Gary, H.E., Jr., Ando, T., Monroe, S.S., Kludt, P.E., Rosenthal, D.S D.S Drainage Structure (flood protection) ., Freeman, J., & Glass, R.I. (1996). 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A foodborne outbreak of Norwalk virus: Evidence for post-recovery transmission. American Journal of Epidemiology, 124(1), 120-126. RELATED ARTICLE: An Outbeak of Norwalk-Like Viral Gastroenteritis in a Frequently Penalized Food Service Operation: A Case for Mandatory Training of Food Handlers in Safety and Hygiene * Norwalk-like viruses (NLVs) caused approximately 96 percent of nonbacterial gastroenteritis outbreaks reported to 33 state health departments from January 1996 to June 1997. * The modes of NLV transmission include --- ingestion of contaminated food or water, and --- person-to-person transmission via direct contact, aerosol, or contaminated objects. * In December 1999, an outbreak of acute gastroenteritis occurred among people who had eaten at a Christmas banquet in Toledo, Ohio. * The meal had been prepared and served by a local caterer. * The source of the outbreak was unknown, but could have been failure to follow safe food-handling practices during preparation, storage, or serving. * An infected but nonsymptomatic food handler also was considered as a likely source. * Employees of the caterer were not available for interview and did not provide stool samples as requested by health department officials. * Some studies have shown that restaurants with poor inspection scores are more likely to contribute to disease outbreaks than restaurants with good inspection scores. * Training of restaurant personnel in food safety and hygiene has been shown to reduce health violations. * The state of Ohio food code allows exemption from one standard inspection per year for high-risk food service operations with personnel certified in food safety and hygiene. * None of the food handlers at the catering facility discussed above had such a certificate. * The catering facility had been cited frequently by health officials for critical food safety violations. * The frequency of the violations may have been due in part to the lack of properly trained personnel. * Training may be necessary for reducing health violations and preventing the occurrence of foodborne outbreaks. |
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