1. Module 7: Personal Hygiene and Employee Health Part 2

2. Case Study

3. If your area doesn’t have Chipotle, explain that it is a fast casual chain that serves custom Tex Mex. Think a Subway for burritos.

4. Chipotle had several large outbreaks in 2015
Chipotle had several large outbreaks in This outbreak at Boston College was the only one where health officials were able to definitively identify the cause

5. What Happened December 2015, Boston, MA
Boston University Health Services began receiving reports of students experiencing vomiting and diarrhea
All students reported eating at the Cleveland Circle Chipotle Restaurant over the weekend

6. What They Found
One employee worked the weekend while ill and later tested positive for Norovirus
Four other employees fell ill after the weekend and also tested positive
Restaurant was closed for sanitation
Over 120 people reported feeling sick after eating at that Chipotle location over that time period

7. Learning Objectives
Understand symptoms, sources and control for Norovirus
Describe how and when to correctly wash hands
Explain proper glove use and ways to prevent bare hand contact
List the correct procedure for cleaning an area where vomit is present

8. Key Terms Excluded employee - cannot work in food establishment
Highly susceptible population – people more likely than other people in the general population to experience foodborne disease (YOPI).
Reinstated employee - approved to work
Restricted employee - cannot work with or around food

9. Norovirus Source Lives in humans Transmitted fecal-oral route Symptoms
Vomiting (projectile)
Diarrhea
Nausea
Abdominal cramps
Though it sounds crude, fecal-oral is the epidemiological term that refers to how pathogens are transferred.
Norovirus can cause severe dehydration
Most people who die from norovirus already have a pre-existing condition

10. Norovirus Special characteristics
Viruses are only able to multiply in the cells of host
Viruses survive refrigeration and freezing
Virus can persist on surfaces up to 6 weeks
Foods associated
Shellfish from contaminated water
Fresh produce
RTE foods
These characteristics are true of all viruses
Remember, shellfish are filter feeders (remember the Finding Nemo reference?) so they can concentrate the viral particles
Produce can be contaminated by contaminated irrigation water or sick harvesters

11. Norovirus Norovirus is often called the “stomach bug” or “stomach flu”
Not related to respiratory flu
Approximately 20 million illnesses in the U.S. annually
56,000 to 71,000 hospitalizations
related deaths
Most common cause of foodborne illness in U.S. (~58%)

12. Norovirus
Infected people can shed large numbers of Norovirus in feces and vomit
Employees who work with symptoms of diarrhea and/or vomiting will spread the virus
Hands may have virus after bathroom use and improper handwashing
Virus particles may be spread to hands, clothes, and other surfaces after vomiting
Some Norovirus infections occur without symptoms (asymptomatic)
One gram of vomit or feces (about the size of a cranberry) can contain enough viral particles to make thousands of people sick

13. Norovirus Outbreaks
70% of Norovirus outbreaks are caused by sick food employees
Norovirus outbreaks are frequently associated with large amounts of people in close quarters
Nursing homes
Daycare centers
Schools
Hotels
Cruise ships
Airplanes
Areas with lots of high touch areas to transfer illness
There have been outbreaks where one vomiting episode in a hallway, classroom, etc lead to dozens of people getting ill

14. Survey shows that 1 in 5 restaurant workers will work with these symptoms
Why do you think that is?
If you can influence policies at work, what do you think would help?

15. Proper Handwashing

16. Handwashing Always use a handwash sink
Must be at least one designated hand sink and bathroom
Adequate water 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 handwashing sinks must have running potable water, soap, hand drying. Foot pedals are ideal. If your sink has handles, make sure to not recontaminate your hands on the handle after 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.
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 some soap.
Every stage in handwashing is equally important and has an additive effect in transient microbial reduction.
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.

17. Proper Handwashing
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
The greatest concentration of microbes exists around and under the fingernails of the hands.

18. What is Required at a Handwashing Sink
Warm running water (100°F)
Soap
Paper towels or hand dryer
Trash can
Reminder sign
Warm water is still a requirement of the food code, but research shows that there is not a significant difference in hand decontamination when washing in warm or cold water
Warm water is more comfortable though, so employees are mostly likely to wash their hands for the recommended time if water temperature is bearable

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

20. After any activity that contaminates hands!
When to Wash Hands
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

21. Hand Sanitizers
Hand sanitizers are not a replacement for thorough and effective handwashing
Can be used after handwashing as a second measure to decontaminate hands
Hand sanitizers do not remove dirt and soil, they just spread it around
Commonly-available, alcohol-based hand sanitizers are not effective against all pathogens, including Norovirus

22. Preventing Bare Hand Contact

23. Preventing Bare Hand Contact
Wear single-use gloves
Use serving utensils such as spoons, ladles and tongs
Use single-use deli or bakery papers

24. Glove Use
Wear single-use gloves when handling all ready-to-eat foods, except washing produce
Always cover a bandaged cut or sore with a single-use glove
Wear slash-resistant gloves when carving meat
Must be smooth, durable and non-absorbent OR
Covered with such a glove OR
Covered with a single use glove
Change gloves whenever switching from raw to ready-to-eat foods

25. Cleaning Vomit and Diarrheal Events

27. 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

28. Cleaning Vomit 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 sit 4 minutes
Wipe up remaining solution, reclean and sanitize
Discard all disposal material in plastic bags double bagged (biohazard bags)

29. Discussion
Do you have policies in place for how to deal with a vomiting episode at your restaurant?

30. Case Study What Happened What They Found
120 people sick with severe nausea, vomiting, diarrhea.
Norovirus was the cause.
Everyone ate at a Chipotle in Cleveland Circle.
Employee was working while ill

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

32. Activity: Proper Handwashing
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

33. 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

34. 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

35. 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

36. 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
Watch the wording ‘at least.’ Recommendation is to rub hands with soap and water for seconds

37. Review Norovirus prevention and control Proper handwashing
Preventing bare hand contact
Cleaning up after illness