Preventing & Controlling

Table of Contents

Introduction

The priority of each investigation is to prevent ongoing and future illness. This should be done as soon as appropriate in the investigation by implementing effective prevention and control measures. Factors to consider when determining the most effective measures may or may not include: the extent of the illness, who was affected, when and where the critical exposure took place, the vehicle, how the disease was transmitted, the etiologic agent and whether there is potential for ongoing or future transmission. Some of this information may not be known early in the investigation, so it is important to focus on what is known to begin prevention and control measures is of most importance to stop or slow spread of disease.  Measures should focus on most likely agents, sources, reservoirs of infection, or practices and should target interruption of the transmission of disease or reduction of exposure to disease. These measures should be instituted as soon as possible to control the current situation and to prevent future problems in the community.

Standard Recommendations for Control

Recommendations for control are meant to prevent further spread of the agent causing the outbreak.  These are general recommendations. When an outbreak is investigated, it is appropriate to have more specific recommendations (i.e., clean the ice machine, steam clean the carpets, do not serve unpasteurized milk, etc.)

  • Keep infected persons from handling foods. As described previously, anyone experiencing vomiting or diarrhea should not attend daycare, school or work and should not prepare food for anyone – this includes handling food at a restaurant or catering establishment, cooking for family members and friends, or preparing foods in institutions such as long term care facilities, childcare facilities, and schools.  In some rare instances local public health agencies may request stool specimens from food handlers for laboratory testing to determine or rule out source of contamination for the agent causing illness.  If stool specimens are not collected to ensure that a food handler is negative, the establishment should then intensify hand washing and implement a no-bare-hand contact policy for people handling foods that are ready-to-eat, such as items on a salad bar.
  • Seize, detain (embargo), stop distribution of, remove, recall, reject, or destroy the epidemiologically implicated lot. The method for controlling an outbreak will depend on factors such as the likely source, location of contamination, extent of contamination, etc.  Taking these actions usually involves working with partners such as the United States Department of Agriculture and the Food and Drug Administration.
  • Cease processing or preparation of the epidemiologically implicated food. If a food has been implicated as the transmission vehicle and is still being processed or prepared, it should be stopped immediately until the necessary steps are taken to prevent contamination.
  • Close the establishment. An establishment may be closed if continuing operation poses an imminent risk to the public’s health or when the problem cannot be corrected.  Reopening may occur when the factors that contributed to the closing are identified and corrected.  This action will require working closely with the owner(s) of the establishment and closing is a last resort after other recommendations have been documented and implemented but unsuccessful.

Exclusion Recommendations

Anyone with symptoms such as vomiting and diarrhea should not go to child care, school or work because of the risk of transmitting the disease.  This is especially true if the symptomatic person handles food for, or works closely with, high-risk people, such as those in child care, long term care or hospitals.

All food workers (in a restaurant or any food-preparation setting) symptomatic with vomiting or diarrhea should be immediately excluded from work. Food managers may overlook these infections because, after the initial onset of symptoms, the illness may appear mild enough to allow the food handler to continue working. Early return to work should be avoided because even relatively low numbers of an infectious agent can be transferred to food and result in transmission of the infectious agent, potentially causing illness. Food handlers should also be made aware that, though rare, they could transfer infectious particles to food via hands and clothing following contact with an ill family member, even though they themselves are not symptomatic. Prevention of food-borne illness outbreaks requires good staff supervision, and food handlers should not be penalized but encouraged to report signs and symptoms of illness as soon as they occur.

[table: Summary of Restrictions and Exclusions: Food Establishments Serving the Public]

[table: Summary of Restrictions and Exclusions: Food Establishments Serving Highly Susceptible Population]

Hepatitis A and Food Handlers

When ill with hepatitis A, there are no special medicines to reduce symptoms or shorten the infectious period.  Generally, bed rest is all that is needed for recovery.  However, when people have close contact with, or have eaten food prepared or served by a person infected with hepatitis A, they should receive immune globulin (IG) (previously called “gamma globulin”).  IG is a shot given to help prevent hepatitis A.  Co-workers of food handlers infected with hepatitis A are advised to get an IG shot as soon as possible, at least within seven days of contact with the infected co-worker.  If this is not done, they will not be allowed to handle food for six weeks.  IG is also recommended for all household members and close contacts (including sexual and drug-sharing contacts) of a person with hepatitis A. The IG should be given as soon as possible within 14 days.  It is important to note that the IG does not guarantee that hepatitis A will not occur; however, if it does not prevent it, it may lower the risk of serious illness.

Closure of a Food Establishment

A food establishment may be closed if an imminent health hazard exists.  Imminent health hazards, as defined by the Iowa Food Code, Chapter 8, Section 404.11, are fire, flood, electrical disruption to sewer and water systems, sewage backup, misuse of poisonous and toxic materials, onset of foodborne illness outbreak or other circumstance that may endanger the public’s health.

[table: General exclusion recommendations for health care institutions and daycare providers]

[table:  General Exclusion Recommendations for general public]

What Everyone Can Do to Reduce the Likelihood of Foodborne Illness

Good Hand Hygiene

When should you wash your hands?  

Any time your hands are dirty AND:

Before you:

  • Eat
  • Prepare food for yourself or others
  • Treat a break or cut in the skin
  • Care for an ill or injured person or animal
  • Insert or remove contact lenses

Immediately after you:

  • Use the restroom
  • Handle uncooked foods (especially raw meat, poultry or fish)
  • Change a diaper or after you help someone use the restroom (Their hands should also be washed)
  • Blow your nose, sneeze, or cough
  • Touch an animal (especially a reptile), including animals in petting zoos and fairs
  • Treat a break or cut in the skin

Why is hand washing important?

Hand washing, when done correctly, is the single most effective way to prevent the spread of communicable diseases. Good hand washing is easy to learn and can significantly reduce the spread of infectious diseases among children and adults. 

What types of disease can good hand washing prevent?

Diseases spread through fecal-oral transmission. Infections that may be transmitted through this route include salmonellosis, shigellosis, hepatitis A, giardiasis, enterovirus, amebiasis, norovirus, rotovirus and campylobacteriosis. Because these diseases are spread through the ingestion of even the tiniest particles of fecal material, hand washing after using the restroom, helping someone use the restroom or changing a diaper, cannot be over-emphasized.
Diseases spread through indirect contact with respiratory secretions. Microorganisms that may be transmitted through this route include influenza, streptococcus, respiratory syncytial virus (RSV) and the common cold. Because these diseases may be spread indirectly by hands freshly soiled by respiratory discharges of infected people, illness may be avoided by washing hands after coughing, sneezing, blowing your nose, or after shaking hands with people who have been coughing, sneezing or blowing their noses.

Diseases may also be spread when hands are contaminated with urine, saliva or other moist body substances. Microorganisms that may be transmitted by one or more of these substances include cytomegalovirus, typhoid, staphylococcal organisms, and Epstein-Barr virus. These organisms may be transmitted from person-to-person or indirectly by contamination of food or inanimate objects, such as toys.

What is good hand washing?

There is more to hand washing than you may think. By rubbing your hands vigorously with soapy water, you pull the dirt and the oily soils free from your skin. The soap lather suspends the dirt and germs trapped inside and are washed away.

Follow these four simple steps in keeping hands clean:

  • Wet your hands with warm running water.
  • Add soap, then rub your hands together, making a soapy lather. Do this away from the running water for at least 20 seconds, being careful not to wash the lather away. Wash the front and back of your hands, as well as between your fingers and under your nails.
  • Rinse your hands well under warm running water. Let the water run back into the sink, not down to your elbows. Turn off the water with a paper towel and dispose of the towel in a proper receptacle.
  • Dry hands thoroughly with a clean towel.

What type of soap should be used?

Any type of soap may be used. However, bar soap should be kept in a self draining holder that is cleaned thoroughly before new bars are put out and liquid soap containers (which must be used in child-care centers) should be used until empty and cleaned before refilling. 

To prevent chapping, use a mild soap with warm water, pat rather than rub hands dry, and apply lotion liberally and frequently.

What are hand-washing mistakes that should be avoided?

  • DON’T use a single damp cloth to wash a group of children’s hands.
  • DON’T use a standing basin of water to rinse hands.
  • DON’T use a common hand towel. Always use disposable towels in child-care or food preparation settings.
  • DON’T use sponges or non-disposable cleaning cloths unless you launder them on a regular basis, adding chlorine bleach to the wash water. Remember that germs thrive on moist surfaces.

How can you help children with good hand washing?

It is important to encourage and help children to wash hands before eating, after playing outdoors or playing with pets, after using the bathroom and after blowing their noses, coughing or sneezing. Even though hands may appear to be clean, they may carry germs or microorganisms that are capable of causing disease.

Don’t assume that children know how to wash their hands properly. Supervision, especially in child care, is essential in forming good hand washing habits in children.

Finally, children learn by example. Let them observe good hand washing from the adults who care for them.

What about alcohol-based hand gels?

These may be used when hand-washing facilities are not available and when hands are not visibly soiled.

Safe Food Handling to Prevent Foodborne Illness At Home

Outside of handwashing there are many other prevention measures individuals can take to prevent foodborne illness.  These prevention measures include following proper cooking temperatures, storing food at proper temperatures, and several other safety tips listed below. 

[table: Proper Cooking Temperatures]

Tips Towards a Safer Kitchen

  • Keep your refrigerator at 41 F (5 C) or less. A temperature of 41 F or less slows the growth of most bacteria. The fewer bacteria, the less likely you are to get sick from them.
  • Wash your cutting board with soap and hot water after each use. Using a bleach solution (approximately 1-capful to a gallon of water or premixed in a spray bottle) to sanitize your cutting board after washing and rinsing is the best way to prevent bacteria from remaining on your cutting board, especially after preparing raw meats or cutting unwashed vegetables or fruits. Washing with only a damp cloth will not remove all bacteria.
  • Never allow raw meat, poultry, eggs or fish to come in contact with other foods.
  • Ground beef can be contaminated with potentially dangerous E. coli 0157:H7 or other bacteria. The Food and Drug Administration (FDA) has recommended the use of a meat thermometer when cooking raw animal foods. Do not rely on the internal color of the meat because some meat may turn prematurely brown before a safe internal temperature is reached.
  • Do not eat raw or lightly cooked eggs. Many older cookbooks have recipes that include raw eggs (e.g., ice cream, mayonnaise and eggnog). These recipes are no longer recommended because of the risk of salmonella. The commercial versions of these products are made with pasteurized eggs and are not a food hazard. 
  • Discard cracked or dirty eggs.
  • Keep eggs refrigerated and eat promptly after cooking. Do not keep eggs, or egg-based foods or sauces, warm for more than two hours.
  • If cooked food items are being served over an extended period, keep cooked food items hot in a crock pot or roaster at a minimum temperature of 135o F or above.
  • Use a calibrated food thermometer to monitor temperatures of cold, hot and cooked foods.
  • Always wash fruits and vegetables thoroughly before cutting or eating.
  • Wash hands with soap and warm water immediately after handling raw meat, raw eggs, poultry, or fish. Wash for at least 20 seconds before and after handling food, especially raw meat. If you have an infection or cut on your hands, wear rubber or plastic gloves.
  • Defrost meat, poultry and fish products in the refrigerator, microwave oven or under cold water. Follow package directions for thawing foods in the microwave. Cook microwave-defrosted food immediately after thawing
  • Use clean cooking utensils, silverware and dishes to prepare and serve all foods. Be especially careful when barbecuing to avoid having a spatula or platter touch both raw and cooked meats.
  • If possible, use clean utensils instead of hands to prepare food.
  • Refrigerate cooked, perishable food as soon as possible, within two hours after cooking. Date leftovers so they can be used within two to three days. “If in doubt, throw it out!”
  • When cooling leftovers in the refrigerator, break large batches of leftovers into smaller quantities (3" to 4" to a container) and leave uncovered in the refrigerator until cooled. Use metal instead of plastic containers. Chill containers that you will be storing food in or provide an ice bath to rapidly chill food down to 41o F. Improper cooling is one of the major causes of foodborne illnesses.
  • Sanitize your kitchen dishcloths regularly. Wash with a solution of one-teaspoon chlorine bleach to one-quart water, or use a commercial sanitizing agent following product directions.  Cloths used for cleaning utensils should be replaced or disinfected daily. The use of sponges is discouraged since they may harbor bacteria and cannot be easily cleaned or sanitized.
  • Clean kitchen counters and other surfaces that come in contact with food using hot water and detergent and a solution of bleach and water. Bleach and commercial disinfectants are best for getting rid of bacteria.  Hot water and detergent do a good job, but may not kill all strains of bacteria.
  • Allow dishes and utensils to air-dry to eliminate re-contamination from hands or towels.  When washing dishes by hand, it’s best to wash them all within two hours of use -- before bacteria begin to multiply.
  • Dented cans should be used as soon as possible; better yet, don’t buy them. Since toxins from the can get into the food.  Cans with bulging ends should not be used under any circumstances.
  • Do not store onions and potatoes together because gases from onions make potatoes rot.
  • Do not store foods under sinks because cleaning supplies or water may contaminate them.
  • Do not save leftover food or milk that a baby does not finish.
  • If foods such as sandwich meats feel slimy, it is because they are coated in bacteria. Throw the food out, or if you just bought it, return it to the store and inform the manager.
  • Flour bugs might be repulsive, but they probably will not make you sick. Insects such as flies and cockroaches can spread bacteria.
  • Accumulated paper and grocery bags can be hangouts for rodents and bugs.
  • Do not put things that are handled a lot but not washed (e.g., playing cards) in the same drawer as utensils.
  • Do not cook or serve food to others if you are ill!
  • Source: Iowa State University, Madison Department of Public Health and the Wisconsin Division of Public Health, Bureau of Environmental and Occupational Health.

Internet Resources for Education

Iowa Food Code: http://www.state.ia.us/government/dia/1997%20Food%20Code%2006.11.04.pdf

The Integrated Food Safety Information Delivery System (IFSIDS) web site serves food safety regulators by providing factual information for use with food-establishment operators.

http://www.profoodsafety.org/

Iowa State University Extension believes that resources are needed for consumers, educators and students to access research-based, unbiased information on food safety and quality. http://www.extension.iastate.edu/foodsafety/

The Iowa Restaurant Association offers a range of educational programs, including: National Food Safety Education Month, ServSafe Food Safety, ServSafe Alcohol, DineSafe, IRA-to-Go, ProStart and the ProStart Competition.  http://www.restaurantiowa.com/education.htm

The Iowa Grocers Industry Association (IGIA), in collaboration with Iowa State University Extension, sponsors SuperSafeMark. Courses are offered throughout the state. http://www.iowagrocers.com/

This is the National Restaurant Association Foundation’s web site for training, promotional materials, and information about National Food Safety Education Month, which occurs every September.

http://www.nraef.org/nfsem/default.asp

Food Safety and Inspection Service web site links to many resources on training tool kits, federal government resources, and certification opportunities.

http://www.fsis.usda.gov/Frame/FrameRedirect.asp?main=http://www.fsis.usda.gov/oa/pubs/fstea.htm