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

2. 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

3. 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

4. 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:

5. 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:

6. 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

7. 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

8. 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

9. EHS-Net Retail Deli Practices Study: Deli and staff characteristics
Deli Characteristics N %
Ownership type (N=298) Chain Independent
55 45
# of customers served on busiest day (N=236) > 300
# of slicers (N=294) 1 or 2 > 3
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
65 35
Food safety knowledge (N=294) Answered < 100% correctly Answered 100% correctly
53 47 9

10. 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

11. 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

12. 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

13. 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

14. 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

15. Resources CDC’s EHS-Net: http://www.cdc.gov/nceh/ehs/EHSNet/index.htm
Retail deli slicer cleaning publication: htm
USDA-FSIS Listeria guidance: tory-compliance/listeria 15

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