1. Module 9: Hand Washing

2. All You Can Eat…Will Come Back Out

4. January 17, 2012 Hickory, NC
Catawba County Public Health received reports of illness after visiting the Harbor Inn Seafood Restaurant located in Hickory, North Carolina
Eight staff members were identified who worked January 12–January 20 while experiencing gastrointestinal symptoms.
166 illnesses identified

5. What Went Wrong
Norovirus is often called the “stomach bug” or “stomach flu”
Not related to respiratory flu
Employees who work with symptoms of diarrhea and/or vomiting will spread the virus
Diarrhea
Hands may have virus after bathroom use and improper hand washing
Vomiting
Virus particles may be spread to hands, clothes, and other surfaces

6. DISCUSSION
Thinking back on our case study, where over 160 people got sick, it would have been pretty simple to prevent this outbreak. Proper personal hygiene was a major risk factor, but it could have all been prevented if the sick employee called in sick or was sent home.

7. Learning Objectives Describe how and when to correctly wash hands
Explain the symptoms, causes, and control methods for Norovirus and Hepatitis A
List the correct procedure for cleaning an area where vomit is present
List four important factors related to viruses

8. Key Terms Exclusion employees Norovirus Hepatitis A Jaundice
Projectile vomiting

9. Only able to multiply in the cells of host
Viruses
Only able to multiply in the cells of host
Transmission routes:
Person to person contact
Infected person to food
Can’t grow in food (but can survive in food and infect someone else)
Infected person to food contact surface
Poor personal hygiene (fecal-oral route)
Survives refrigeration and freezing
Fecal-people

10. NOROVIRUS is the most common cause of gastroenteritis in U.S.
Barfblog.com

11. Norovirus Approximately 20 million illnesses annually
56,000 to 71,000 hospitalizations
related deaths
Most common cause of foodborne illness in U.S. (~58%)

12. Facts about Norovirus
Some Norovirus infections occur without symptoms (asymptomatic)
Infected people can shed large numbers of Norovirus in feces and vomit
Virus can persist on surfaces up to 6 weeks
Commonly available, alcohol-based hand sanitizers are not effective against norovirus

13. Symptoms
Vomiting (projectile)
Diarrhea
Nausea
Abdominal cramps

14. Foods Involved Ready to Eat Foods Contaminated by infected person
Produce
(e.g. cut fruit, salads)
Shellfish
Contaminated water

15. Places with large amounts of people in close quarters
Locations
Nursing homes
Daycare centers
Schools
Hotels
Cruise ships
Airplanes
Places with large amounts of people in close quarters

16. 70% of Norovirus outbreaks are caused by food handlers
Control
70% of Norovirus outbreaks are caused by food handlers
Monitor employee health
Exclude employees with vomiting and diarrhea and confirmed Norovirus
Enforce personal hygiene (wash hands after bathroom)
Rinse produce with potable water
Clean and disinfect kitchen utensils and counters
Clean and disinfect any area with vomit

17. Hepatitis A is another Type of Virus.
Bad press, sick customers.

18. Hepatitis A Virus Symptoms: Fever Weakness Nausea Abdominal Pain
Jaundice
Can take up to 50 days for symptoms to appear

19. Foods Involved Ready to eat foods
Shellfish harvested from contaminated waters
Any food contaminated by employee
Spread through fecal-oral transmission

20. Control Exclude employees with symptoms or confirmed Hepatitis A
Good personal hygiene
Wash hands after using the bathroom
No bare hand contact with RTE foods
Shellfish
Purchase from approved suppliers
Cook shellfish properly
Retain shellfish tag for 90 days

21. Proper Hand Washing
Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to ready-to-eat (RTE) food as well as other pathogens that can be transmitted from environmental sources. Many employees fail to wash their hands as often as necessary and even those who do may use flawed techniques.
In the case of a food worker with one hand or a hand-like prosthesis, the Equal Employment Opportunity Commission has agreed that this requirement for thorough handwashing can be met through reasonable accommodation in accordance with the Americans with Disabilities Act. Devices are available which can be attached to a lavatory to enable the food worker with one hand to adequately generate the necessary friction to achieve the intent of this requirement.
The greatest concentration of microbes exists around and under the fingernails of the hands. The area under the fingernails, known as the “subungal space”, has by far the largest concentration of microbes on the hand and this is also the most difficult area of the hand to decontaminate. Fingernail brushes, if used properly, have been found to be effective tools in decontaminating this area of the hand. Proper use of single-use fingernail brushes, or designated individual fingernail brushes for each employee, during the handwashing procedure can achieve up to a 5-log reduction in microorganisms on the hands.
There are two different types of microbes on the hands, transient and resident microbes. Transient microbes consist of contaminating pathogens which are loosely attached to the skin surface and do not survive or multiply. A moderate number of these organisms can be removed with adequate handwashing. Resident microbes consist of a relatively stable population that survive and multiply on the skin and they are not easily washed off the hands. Resident microbes on the hands are usually not a concern for potential contamination in food service.
All aspects of proper handwashing are important in reducing microbial transients on the hands. However, friction and water have been found to play the most important role. This is why the amount of time spent scrubbing the hands is critical in proper handwashing. It takes more than just the use of soap and running water to remove the transient pathogens that may be present. It is the abrasive action obtained by vigorously rubbing the surfaces being cleaned that loosens the transient microorganisms on the hands.
Research has shown a minimum second scrub is necessary to remove transient pathogens from the hands and when an antimicrobial soap is used, a minimum of 15 seconds is required. Soap is important for the surfactant effect in removing soil from the hands and a warm water temperature is important in achieving the maximum surfactant effect of the soap.
Every stage in handwashing is equally important and has an additive effect in transient microbial reduction. Therefore, effective handwashing must include scrubbing, rinsing, and drying the hands. When done properly, each stage of handwashing further decreases the transient microbial load on the hands. It is equally important to avoid recontaminating hands by avoiding direct hand contact with heavily contaminated environmental sources, such as manually operated handwashing sink faucets, paper towel dispensers, and rest room door handles after the handwashing procedure. This can be accomplished by obtaining a paper towel from its dispenser before the handwashing procedure, then, after handwashing, using the paper towel to operate the hand sink faucet handles and restroom door handles.
Handwashing done properly can result in a 2-3 log reduction in transient bacteria and a 2-log reduction in transient viruses and protozoa. With heavy contamination of transient microbial pathogens, (i.e., > 104 microbes, as found on hands contaminated with bodily wastes and infected bodily fluids) handwashing may be ineffective in completely decontaminating the hands. Therefore, a further intervention such as a barrier between hands and ready-to-eat food is necessary.
Hand sanitizers use:
Effectiveness of Liquid Soap and Hand Sanitizer against Norwalk Virus on Contaminated Hands Applied and Environmental Microbiology

22. Hand Washing Always use a hand wash sink
Must be at least one designated hand sink and bathroom
Adequate flow and quality
Temperature at least 100°F
Wet hands and exposed parts of arms with warm water and soap
Rub soap into hands and arms for seconds
Rinse hands and arms with warm water Whole process should take 20 seconds
Dry hands and arms on disposable paper towel or electric dryer
Highlight that hand washing sinks must have running potable water, soap, hand drying. Foot pedals are ideal. If your sink has handles, make to not recontaminate your hands on the handle after washing.

23. What is Required at a Hand Washing Sink
Warm running water (100°F)
Soap
Paper towels/hand dryer
Trash can
Reminder sign

24. When to Wash Hands Before Starting work Touching raw or TCS food
Touching ready-to-eat food
Putting on new gloves
During
Food preparation as frequently as required to maintain clean hands and prevent cross-contamination
Switching between raw and cooked food
Switching between raw and ready-to-eat food

25. When to Wash Hands (continued)
After
Handling raw food
Using bathroom
Coughing, sneezing, blowing nose
Touching handkerchief, hair, face.
Cleaning/sanitizing
Removing garbage
Changing protective gloves
Breaks
Eating, drinking, smoking
Touching money
After any activity that contaminates hands!
Example: Bojangle’s biscuits- they handle money at the cash resister, and should not handle your food. Tongs should be used to prevent possible cross contamination, or they should wash their hands and reglove

27. Reporting Illness/Exclusion
Employees must report to “person in charge”
If diagnosed with:
Hepatitis A
E.coli 0157:H7
Norovirus
Salmonella species
Shigella species
Have had a past illness from above or live in household where someone has had above
Traveled within last 50 days to an area outside U.S. with an epidemic from above
HENSS
HENSS can be used as an acronym for the exclusion diseases

28. Reporting Illness/Exclusion
Employee has following symptoms:
Diarrhea, vomiting
Fever, jaundice
Sore throat and fever*
Employee has a draining boil or open infected wound
Employee suspected of causing or being exposed to confirmed illness outbreak
Excluded employee-can’t work in operation
Restricted employee-can’t work with or around food
Reinstated employee-approved to work
Sore throat and fever is restricted unless working with highly susceptible populations

29. Employees Need To Know The Rules Example form from Food Code

30. Employee Restriction vs. Exclusion
Restricted employee – can’t work with or around food
Excluded employee – can’t work in establishment
Symptoms of sore throat and fever may exclude or restrict
Must be excluded if serving highly susceptible population
Covered open wounds or cuts

31. Returning to Work Reinstated employee – approved to work
Mandatory reporting illnesses:
Need written clearance from a medical professional or health official
Symptoms only:
Must be symptom free for 24 hours
Check with health department for specifics

32. Ratemyvomit.com

33. Cleaning Vomit Personal Protective Equipment Disposable latex gloves
Surgical mask, plastic apron
Biohazard bag
Cleaning Area
Virus can mist from vomiting can be spread up to 30 feet outside the visual area
Sanitizers – concentration and time are important

35. Cleaning (continued) Cleaning procedure
Using protective equipment, carefully wipe up spill using paper towels and bag waste
Pour bleach (5,000ppm or 1:10 dilution) or other recommended disinfectant around the area and let it stay 4 minutes
Wipe up remaining solution, reclean and sanitize
Discard all disposal material in plastic bags double bagged (biohazard bags)

36. How do you talk to employees about illness and staying home?
What’s Your View?
How do you talk to employees about illness and staying home?

37. Case Study What Happened What They Found
166 people sick with severe nausea, vomiting, diarrhea.
Norovirus was the cause.
What They Found
Everyone ate at a seafood restaurant

38. Case Study What Went Wrong Prevention Employees were working when sick
Not washing hands properly
Prevention
Exclude sick employees
Proper hand washing
Clean up vomit properly

39. Activity: Proper Hand Washing
Glow Germ and black light for volunteers

40. Quiz A food handler must always wash his or her hands:
Before starting work
During food preparation as often as necessary to keep their hands clean and to prevent cross-contamination
When switching between handling raw and ready-to-eat food
All of the above
Answer: D

41. Quiz A food handler must always wash his or her hands:
Before starting work
During food preparation as often as necessary to keep their hands clean and to prevent cross-contamination
When switching between handling raw and ready-to-eat food
All of the above
Answer: D

42. Quiz
When washing hands, rub the soap into your hands and arms vigorously for at least:
15 seconds
10 seconds
20 seconds
30 seconds
Answer b) 10 seconds
Must vigorously scrub for seconds. The whole wash should take about 20 seconds

43. Quiz
When washing hands, rub the soap into your hands and arms vigorously for at least:
15 seconds
10 seconds
20 seconds
30 seconds
Answer b) 10 seconds
Must vigorously scrub for seconds. The whole wash should take about 20 seconds

44. Quiz Which fact about viruses is INCORRECT?
Viruses feed off of food particles in contaminated foods and multiply
Viruses need to infect a host to multiply
Viruses can survive on hand contact surfaces for up to 6 weeks if not cleaned and sanitized
It can take up to 50 days for Hepatitis A symptoms to appear
Answer: a) Viruses don’t reproduce in the food. Viruses infect a host in order to reproduce/multiply

45. Quiz Which fact about viruses is INCORRECT?
Viruses feed off of food particles in contaminated foods and multiply
Viruses need to infect a host to multiply
Viruses can survive on hand contact surfaces for up to 6 weeks if not cleaned and sanitized
It can take up to 50 days for Hepatitis A symptoms to appear
Answer: a) Viruses don’t reproduce in the food. Viruses infect a host in order to reproduce/multiply

46. Summary Norovirus and Hepatitis A Sick employees Hand washing
Cleaning up after illness