CDC’s Retail Deli Practices Study Erik Coleman, MPH National Center for Environmental Health Division of Emergency and Environmental Health Services

CDC’s Environmental Health Specialists Network (EHS-Net) Since 2000, CDC has funded state and local health departments to conduct research that contributes to our understanding of environmental causes of foodborne illness outbreaks Focus on retail food safety policies and practices EHS-Net is a collaborative program of federal, state, and local environmental health/food safety specialists and epidemiologists EHS-Net USDA FDA CDC CDC-funded state and local sites 2

EHS-Net Retail Deli Practices Study In 2012, EHS-Net conducted a USDA-FSIS-funded study Retail deli policies and practices likely associated with Listeria monocytogenes cross-contamination Because of our ability to collect real-time data in retail establishments, USDA-FSIS funded us to conduct a study on retail deli policies and practices associated with Listeria cross-contamination. 3

Listeria monocytogenes About 1,600 people in the US get sick from Listeria germs each year. Listeria is the 3rd leading cause of death from food poisoning. At least 90% of people who get Listeria infections are either pregnant women and their newborns, people 65 or older, or people with weakened immune. In 2012, 831 foodborne outbreaks were reported to CDC. There were 4 confirmed outbreaks and 1 suspected outbreak of listeriosis in the United States. The largest listeriosis outbreak in U.S. history occurred in 2011, when 147 illnesses, 33 deaths, and 1 miscarriage occurred among residents of 28 states; the outbreak was associated with consumption of cantaloupe from a single farm CDC estimates that approximately 1600 illnesses and 260 deaths due to listeriosis occur annually in the United States. Listeriosis, a serious infection usually caused by eating food contaminated with the bacterium Listeria monocytogenes, is an important public health problem in the United States. The disease primarily affects older adults, pregnant women, newborns, and adults with weakened immune systems. However, rarely, persons without these risk factors can also be affected. The risk may be reduced by following recommendations for safe food preparation, consumption, and storage. Source: http://www.cdc.gov/vitalsigns/listeria/index.html

Preventing Listeria monocytogenes Rinse raw produce, such as fruits and vegetables. Scrub firm produce (e.g. melons). Separate uncooked meats and poultry from vegetables, cooked foods, and ready-to-eat foods. Cook meat and poultry thoroughly. Avoid raw (unpasteurized) milk, and avoid foods made with unpasteurized milk There are some general recommendations on how to prevent an infection with Listeria FDA recommendations for Washing and handling food. •Rinse raw produce, such as fruits and vegetables, thoroughly under running tap water before eating, cutting, or cooking. Even if the produce will be peeled, it should still be washed first. •Scrub firm produce, such as melons and cucumbers, with a clean produce brush. •Dry the produce with a clean cloth or paper towel. •Separate uncooked meats and poultry from vegetables, cooked foods, and ready-to-eat foods. Keep your kitchen and environment cleaner and safer. •Wash hands, knives, countertops, and cutting boards after handling and preparing uncooked foods. •Be aware that Listeria monocytogenes can grow in foods in the refrigerator. Use an appliance thermometer, such as a refrigerator thermometer, to check the temperature inside your refrigerator. The refrigerator should be 40°F or lower and the freezer 0°F or lower. •Clean up all spills in your refrigerator right away–especially juices from hot dog and lunch meat packages, raw meat, and raw poultry. •Clean the inside walls and shelves of your refrigerator with hot water and liquid soap, then rinse. Cook meat and poultry thoroughly. •Thoroughly cook raw food from animal sources, such as beef, pork, or poultry to a safe internal temperature. For a list of recommended temperatures for meat and poultry Store foods safely. •Use precooked or ready-to-eat food as soon as you can. Do not store the product in the refrigerator beyond the use-by date; follow USDA refrigerator storage time guidelines: ◦Hot Dogs – store opened package no longer than 1 week and unopened package no longer than 2 weeks in the refrigerator. ◦Luncheon and Deli Meat – store factory-sealed, unopened package no longer than 2 weeks. Store opened packages and meat sliced at a local deli no longer than 3 to 5 days in the refrigerator. •Divide leftovers into shallow containers to promote rapid, even cooling. Cover with airtight lids or enclose in plastic wrap or aluminum foil. Use leftovers within 3 to 4 days. Choose safer foods. •Do not drink raw (unpasteurized) milk, and do not eat foods that have unpasteurized milk in them. Source: http://www.cdc.gov/listeria/prevention.html

EHS-Net Retail Deli Practices Study Why Listeria? Why retail delis? Why cross- contamination? It is a foodborne bacterium that causes a serious infection (listeriosis). It causes the 3rd highest number of deaths from foodborne disease annually. It mostly affects: older adults pregnant women newborns adults with weakened immune systems. Deli meats are the major source of listeriosis illnesses. Deli meats sliced and packaged at retail are the major source of listeriosis illnesses linked with deli meat. Listeria is persistent in the environment, providing cross- contamination opportunities. Eliminating cross-contamination in delis would decrease risk of illness from ready-to-eat retail deli food by 34%. Why Listeria? -Listeriosis is rare, but its fatality rate is very high (about 16 percent, compared with 0.5 percent for either Salmonella or E. coli O157:H7) (Scallan et. al., 2011). Why retail delis? -Ready-to-eat foods such as deli meats, deli salads, and soft cheeses are among those foods that have a greater potential for L. monocytogenes contamination. Of 23 ready-to-eat food categories linked to L. monocytogenes, deli meats pose the greatest risk of listeriosis per year and per serving (FDA/USDA/CDC, 2003). -Approximately 80% of the listeriosis cases associated with deli meats resulted from those sliced at retail, despite the fact that retail-sliced deli meats accounted for only 53% of consumption (Endrikat et al., 2010; Pradhan et al., 2010). Why cross contamination? -Risk assessment data show that eliminating all points of cross-contamination in the deli would decrease the predicted risk of illness from the consumption of RTE products prepared or sliced in the retail deli by approximately 34%. -mention slicers are a key source of contamination in delis 6

EHS-Net Retail Deli Practices Study- Goals Data to be used to inform USDA-FSIS risk assessment activities Identify events that could lead to cross-contamination Estimate the risk of cross-contamination associated with specific actions 1. Collect descriptive data on deli workers’ actions Cleaning policies and practices- slicers, other equipment Hand washing 2. Collect descriptive data on delis’ cross- contamination policies and practices Deli size, ownership Staff food safety knowledge and training 3. Assess relationships among deli and staff characteristics, and deli practices The goals of this study are three-fold…. These data will identify gaps in retail deli policies and practices that contribute to cross-contamination of equipment and ready-to-eat foods and determine how retail deli and staff characteristics are related to cross-contamination practices In the long run, the data can be used to develop effective strategies for the intervention and prevention of future L. monocytogenes contamination in deli ready-to-eat foods.   7

EHS-Net Retail Deli Practices Study: Data collection EHS-Net CDC and site staff developed the study protocol, with FSIS input EHS-Net site staff collected data in randomly selected retail delis in 6 CDC-funded sites: California New York City Minnesota Rhode Island New York State Tennessee Manager interview (N=298) Deli and manager characteristics Cross- contamination and food safety policies and practices Worker interview (N=294) Worker characteristics Cross- contamination and food safety practices Structured observation Slicer and sink number and condition Cross- contamination evidence Notational observation Individual workers’ actions 7

EHS-Net Retail Deli Practices Study: Deli and staff characteristics Deli Characteristics N % Ownership type (N=298) Chain Independent 164 134 55 45 # of customers served on busiest day (N=236) 0-99 100-299 > 300 85 92 59 36 39 25 # of slicers (N=294) 1 or 2 > 3 167 127 57 43 Deli-required manager food safety training (N=295) Yes No 220 75 75 25 Deli has written slicer cleaning policy (N=296) Yes No 194 102 66 34 Manager Characteristics N % Experience in deli (N=298) >5 years 156 142 52 48 Manager is food safety certified (N=297) Yes No 203 94 68 32 Food safety knowledge (N=298) Answered < 75% correctly Answered > 75% correctly 97 201 33 67 Worker Characteristics N % Experience in current deli (N=294) < 5 years 5 years 194 104 65 35 Food safety knowledge (N=294) Answered < 100% correctly Answered 100% correctly 157 137 53 47 9

EHS-Net Retail Deli Practices Study: Slicer cleaning What proportion of delis are fully cleaning their slicers at the FDA-recommended frequency of at least every 4 hours? Which deli and staff characteristics are linked with delis fully cleaning their slicers at the FDA-recommended frequency? We have analyzed a portion of the data from this study- data on slicer cleaning frequency. These data were recently published. The publication focuses on these two questions: Fully cleaning=break down, clean, sanitize Fully cleaning -Disassemble -Clean -Sanitize 1010

EHS-Net Retail Deli Practices Study: Slicer cleaning findings What proportion of delis are fully cleaning their slicers at the FDA-recommended frequency of at least every 4 hours? 10

EHS-Net Retail Deli Practices Study: Slicer cleaning findings Which deli and staff characteristics are linked with delis fully cleaning their slicers at the FDA-recommended frequency? Chain delis Deli-required food safety manager training All slicers cleaned at FDA-recommended frequency More customers Deli manager is food safety certified More slicers Food safety knowledgeable workers Slicers were fully cleaned more frequently in chain delis, and in delis with more customers (>100 on busiest day), more slicers (3 or more), required manager food safety training, food safety–certified managers, food safety–knowledgeable workers (worker answered all food safety questions correctly), and written slicer cleaning policies, than in delis in other categories. Written slicer cleaning policies 12

EHS-Net Retail Deli Practices Study: Slicer cleaning conclusions and recommendations Many delis are not engaging in FDA-recommended slicer cleaning practices that reduce cross-contamination risk Required manager/worker training and certification should be encouraged Development and implementation of written slicer cleaning policies should be considered Interventions should focus on independent and smaller delis 13

EHS-Net Retail Deli Practices Study: Next Steps USDA-FSIS will analyze and disseminate the notational observation data on individual workers’ actions CDC and USDA-FSIS will analyze and disseminate remaining data 14

Resources CDC’s EHS-Net: http://www.cdc.gov/nceh/ehs/EHSNet/index.htm Retail deli slicer cleaning publication: http://www.cdc.gov/mmwr/volumes/65/wr/mm6512a2. htm USDA-FSIS Listeria guidance: http://www.fsis.usda.gov/wps/portal/fsis/topics/regula tory-compliance/listeria 15

Erik W. Coleman - HYE1@CDC.GOV Thank You! Erik W. Coleman - HYE1@CDC.GOV National Center for Environmental Health Division of Emergency and Environmental Health Services