Foodborne Illness Risk Factors

The Centers for Disease Control and Prevention (CDC) research indicates there are certain practices that contribute to most foodborne illness outbreaks. These practices fall into five broad categories known as foodborne illness risk factors. They focus on areas including:

1. Employee health and hygiene 
2. Food sources
3. Cooking
4. Food temperatures
5. Sources of contamination

Systematically reducing the occurrence of these risk factors reduces the risk to food safety and consumer health. Click on each risk factor to learn more about what it covers, why it’s a concern, and how to reduce its occurrence. 

Risk Factor: Employee Health and Hygiene

Most foodborne illness outbreaks are associated with food worker health and hygiene. This indicates more training and resources are necessary to address prevention of foodborne illnesses.

Employee Illness

A foodborne illness is caused by ingesting food that has been contaminated with germs or toxic substances and can sometimes be life threatening. Symptoms can include nausea, vomiting, diarrhea, or fever and can occur within hours or days after consumption of the contaminated food.

Preventing food workers from handling food when they or a family member is ill can prevent a foodborne illness outbreak.

The symptoms below must be reported to the Person In Charge (PIC) at the food establishment and the affected food workers must be excluded from working with food:

• Diarrhea
• Vomiting
• Jaundice (yellowing of the skin and eyes)
• Sore throat with fever
• Open infected wound

Reporting

The food establishment's PIC is responsible for reporting symptoms and confirmed cases of foodborne illnesses to the regulatory authority or licensing entity. A helpful way to remember the foodborne illnesses that must be reported is the acronym HENSS which stands for: 

• Hepatitis A virus
• Shiga toxin-producing E. coli
• Norovirus
• Shigella spp. 
• Salmonella spp. 

Reporting a Suspected Foodborne Illness

The Minnesota Department of Health (MDH) manages foodborne and waterborne illnesses. To report a suspected foodborne or waterborne illness you can:

• Call 1-877-FOOD-ILL (1-877-366-3455) from within Minnesota
• Submit your report using the Foodborne and Waterborne Illness Report, a confidential online survey
• Or email health.foodill@state.mn.us

Visit Reporting Suspected Foodborne and Waterborne Illness for more information. 

Returning to Work 

Employees must be symptom free for 24 hours prior to returning to work. This means an employee experiencing illness on a scheduled day off may still be required to report symptoms to the person in charge if they are scheduled to return to work before they have been symptom free for at least 24 hours.

It can be confusing to determine when a food employee can return to food handling practices as some symptoms can occur for other reasons beyond a foodborne illness. Utilize the illness symptoms action guidance chart (PDF) to help make the appropriate determination. It lists illnesses/conditions, the action food workers should take and the criteria for returning to work.

Creating an Employee Illness Policy

All food establishments must have an employee illness policy and it’s encouraged to have this policy in writing. The policy needs to include:

• Reportable symptoms and the five foodborne illness diseases (HENSS), 
• What to do when food employees experience reportable symptoms, 
• What to do if an employee test positive for a reportable disease (HENSS):
  • Hepatitis A virus
  • Shiga toxin-producing E. Coli
  • Norovirus
  • Shigella spp. 
  • Salmonella spp.
• When employees are allowed to return to food handling tasks

The food establishment should have a system to train employees, receive notice of illnesses, and track the information. 

Training

Training on such an important topic should be done often to ensure staff are knowledgeable and confident on their role and responsibility to report symptoms. The more often employee illness training occurs, the more likely employees are to follow the procedures if they become ill.

Tips for Training 

• Post handouts such as Employee Illness Decision Guide (PDF) in places employees gather or stand such as near the handwashing sink. 
• Highlight employee illness topics during daily, weekly and monthly meetings. Include food employees and management, reminding everyone of the policy.
• Remind staff seasonally, such as during winter months when norovirus, commonly referred to as the stomach flu, peaks in January and February.
• Upon beginning a shift, create a system to confirm an employee does not have a reportable symptom before handling food. This could be a questionnaire specifically asking about symptoms. 

Receiving Notice of an Ill Employee and Tracking Food Employee Illness

The food establishment should designate at least one individual during every shift for food employees to report illness to. They will need to be trained on what information to collect, and what to do with the information once collected.

An illness log is a tool used to document when food employees are experiencing any of the reportable symptoms. This tool can be used to assist inspectors during complaints or outbreak investigations. The lack of an accurate employee illness log can slow the investigation, which may allow additional staff or patrons to get sick.

Tips for Receiving Notice of an Ill Employee and Using an Illness Log

• Use one system throughout the establishment to ensure consistency.
• Ensure the PIC has access to an illness log and that they are aware of their responsibility to properly record the specific reportable illnesses. Writing "sick" is not adequate. 
• The log should be located at the establishment and can be made available promptly when requested. 
• Use the illness log regularly. If no one has reported an illness, record on the log "no reports for the month". 
• Track when an employee is brought back to work after being symptom free for 24 hours.

Personal Hygiene

Handwashing reduces the spread of pathogenic microorganisms transmitted to food when conducted properly and at the right times and locations. Proper handwashing includes using soap and water and rubbing hands vigorously. It must be conducted in a designated handwashing sink that is easily accessible to the food preparation area. 

How to Wash Your Hands

1. Wet your hands
2. Apply soap
3. Rub your hands for 10 to 15 seconds
4. Rinse your hands
5. Dry your hands using a disposable towel
6. Use the disposable towel to turn off the faucet
7. Keep hands clean

The entire process must last at least 20 seconds. See a video on how to properly wash hands: Hand Hygiene 

Gloves, wet-wipes, or hand antiseptics are not substitutes for handwashing, but rather additional tools that can be used. This is because not all hand antiseptics or hand sanitizers are effective at killing viruses such as norovirus.  For more information, the CDC explains the science as to why hand sanitizer is not effective. 

When to Wash Hands

Refer to the Handwashing for Employees factsheet (PDF), (Hmong PDF), (Somali PDF), (Spanish PDF), for specifics on when to wash hands. Hands should be washed anytime before an employee handles food or clean utensils. 

Not only is temperature a factor in keeping TCS foods safe, but so is time. For ready-to-eat (RTE) TCS foods datemarking is required to ensure the food is not used past seven days once it is opened or prepared. Datemarking helps control the growth of microorganisms, such as Listeria, which if present, can grow in refrigerated environments. That is an example of why it is important to limit the amount of time foods are held in the retail establishment. Check out the Date Marking (PDF), (Somali PDF), (Spanish PDF), fact sheet for an easy reference to print.

Suggestions for datemarking:

• The day the food is prepared is day one. Add six days to the date label for a total of seven days the TCS food can be used.
• Train food employees to mark foods using the same method to clearly indicate "open" versus "discard" on the packages.
• If it’s unclear whether a food requires datemarking, check the Minnesota Food Code or ask your inspector. All open or prepared RTE TCS foods are required to have a datemark unless specifically excluded.

Risk Factor: Contaminated Food/Equipment

Cross contamination is the unintentional transfer of bacteria from one surface to another surface. This could be from unclean hands or equipment that touch food, or from raw animal foods that touch or drip onto foods that are ready-to-eat (RTE). To prevent cross contamination, food must be handled safely during receiving, storage, preparation, and display. There are three main methods food becomes contaminated, they are:

• Contamination from food including raw animal food or raw, unwashed produce,
• Contamination from the environment such as dirty food contact surfaces (knives, cutting boards, slicers, etc.),
• Contamination from a food employee’s soiled hands or gloves.

Tips for preventing cross contamination during production:

• Wash hands after handling raw animal foods or touching unclean surfaces.
• Use gloves for one task and remove them after handling food and before handling clean equipment. For more information refer to Preventing Contamination from Hands (PDF), (Somali PDF), (Spanish PDF) fact sheet. 
• Wash, rinse, and sanitize equipment between handling different raw animal species such as beef, pork, and poultry, and in between handling any raw RTE foods and RTE foods. Check out the Cleaning and Sanitizing (PDF), (Somali PDF), (Spanish PDF), fact sheet to learn more about the cleaning process.
• Consider the production order. Plan to start production with foods that don’t require cooking, moving to foods that require the lowest cooking temperature, and ending with preparing foods that require the hottest cooking temperature. For example, start with RTE foods, then move on to fish, then beef and pork, followed by ground beef or ground pork, and end with poultry.

  

• Color code equipment such as cutting boards to know which food item is designated for that equipment. An example is green cutting boards are only used to cut produce and white cutting boards are used for sandwich making.
• Dedicate specific areas for tasks and do not use them for any other purposes, such as a raw chicken prep space.

Tips for preventing cross contamination during storage:

• Use dividers or barriers in display cases that prevent leaking or spilling onto other foods.
• Store RTE food on the top shelves or displays with food that requires a hotter cooking temperature on the shelves below. Poultry requires the hottest cooking temperature and therefore it should be stored on the bottom shelf.
• Chemicals must be below or away from food and food containers.
• Foods should be covered when not actively cooling to prevent contamination.

Contaminated Equipment

Food contact surfaces are required to be properly cleaned which includes a wash, rinse and sanitize step. When equipment or utensils are not cleaned properly, they can become a source of contamination.

Food employees must know when and how to effectively clean and sanitize food contact surfaces, this includes knowing how to check the strength of the chemical sanitizer or the temperature of the hot water sanitizer.

Equipment that touches RTE TCS foods is required to be cleaned at a minimum of every four hours. For alternate cleaning frequencies in refrigerated spaces, refer to the Minnesota Food Code  for the time and temperature parameters. If one of these options is used, a log to record the temperature of the room is required.

Tips for cleaning equipment:

• If using a chemical sanitize method, food employees must know how to use the test strips. Follow the directions on both the sanitizer and test strips.
• For dishwashers that use heat as the sanitizer, such as a mechanical dishwasher, a waterproof thermometer or gauge is necessary to check the proper surface temperature of 160°F was reached.
• For difficult to clean items such as a meat tenderizer, place them in hot soapy water immediately after use to prevent food from drying on the equipment.
• Inspect equipment before it’s used to check for cleanliness. The use of a flashlight on equipment such as slicers, band saws or grinders can help to see food that is not easily visible.
• Use a timer or log to remind food employees when the equipment is due to be cleaned.
• For equipment that cannot be placed in a 3-compartment sink, three buckets may be helpful to complete the wash, rinse, sanitize steps.