Article
A Powerful Case for Diligent Hand Sanitation in the Restaurant and Proper Practices to Achieve It
One of the great ironies of life is that the advice dispensed to us by our mothers can have such a great effect on our well-being. There are few folks who were not coached in the importance of frequent handwashing to remain healthy and to avoid infecting others with our illnesses. For folks who work in the restaurant business, this advice is not only a good rule to live by, it can spare your patrons severe illness.
In this article, we look at the science and practices of proper hand sanitation in the restaurant. One of your greatest responsibilities in operating a restaurant is creating a stringent system of hand sanitation, educating each employee on its practices, and monitoring it to ensure it is being followed. While handwashing seems like such a simple food safety practice, when done frequently and properly, it is one of the most effective sanitation measures in the restaurant. In fact, the Centers for Disease Control and Prevention (CDC) has reported that handwashing is the most important method in preventing the spread of pathogens that cause foodborne illness.
Fatal Interaction
The scientific and medical communities have been attentive to the topic of Escherichia coli O157:H7 (E. coli) since the early 1980s. It was then that the pathogen was first linked to human illness in an outbreak associated with hamburgers from McDonald's®. Soon after this outbreak, researchers discovered that the E. coli pathogen had interacted with Shigella, a better-known virulent pathogen. The interaction resulted in the production of toxins that cause the illness now associated with the E. coli strain.
In 1985, epidemiologists documented E. coli as the leading cause of acute kidney failure in children. In 1992, they further concluded that it was the most common bacterial cause of bloody diarrhea.
One of the most media-attentive outbreaks of E. coli in the United States surfaced in 1993, when a Seattle pediatrician noticed an unusual increase in the number of child patients with bloody diarrhea. Within a week of notifying Washington health officials about a possible foodborne disease outbreak, the pathogen was identified. Investigators traced the outbreak to Jack in the Box® restaurants, which number 1,950 operations in 17 states.
Investigators soon discovered the E. coli strain in contaminated hamburgers that resulted from errors in meat processing and cooking. It involved 73 Jack in the Box® restaurants in Washington, Idaho, California and Nevada. Seven hundred people became ill and four children died as a result of the outbreak.
While tainted hamburger meat caused the Jack in the Box® incident, the repercussions the company experienced were the same as if the pathogen had been from another source -- such as improper workers' handwashing practices. Within 18 months following the outbreak, Jack in the Box® and its parent company, Foodmaker Inc., lost about $160 million in reduced sales and other costs. These costs included those associated with the company's voluntary recall of all hamburger meat from its restaurants and the associated legal costs. Ill customers and parents of ill or deceased children filed several lawsuits against the company. All cases were settled out of court, with one family receiving more than $15 million for a child who was brain-damaged.
Stockholders also filed suit against the company for court costs and lost sales due to adverse publicity; however, the outbreak also led to reform and unification. The federal government, including the Food and Drug Administration (FDA), U.S. Department of Agriculture (USDA), and Food Safety and Inspection Service (FSIS) initiated several programs related to food safety. It also accelerated efforts to modernize federal requirements for food safety using the Pathogen Reduction: Hazard Analysis and Critical Control Point (HACCP) Systems.
The incident also spurred action by officials at Jack in the Box®, which have since become one of the most ardent food safety advocates in the world. It further united parents and concerned citizens to create the first consumer activist group devoted to food safety, Safe Tables Our Priority (STOP). STOP is now considered at congressional and USDA hearings, professional conferences, and in the media a visible lobbying group for safer food.
They're Out There -- the New Foodborne Pathogens
Many other foodborne pathogen outbreaks have occurred since the Jack in the Box® incident. All have included illness, and some have resulted in death.
New pathogens, some believed to be the result of known pathogens combining to create new strains, have surfaced. The cause of pathogen outbreaks in restaurants and foodservice operations has broadened to include other food item sources, as well as other causes. One of the most evident causes is poor handwashing procedures among workers.
Wendy Fanaselle, consumer safety officer with the FDA Department of Health & Human Resources, Center for Food Safety & Applied Nutrition, says an updated list of known pathogens related to food is maintained in the USDA's Food Code.
"The pathogen list is then divided into sections that designate the route by which the pathogens are transmitted," Fanaselle says. "Those that can be transmitted by improperly cleaned hands fall into three categories. Pathogens that spread through a fecal oral route include a variety of Norovirus, Hepatitis, Salmonella and Shigella strains. A couple of pathogens are transmitted by hand through skin infections, such as boils, cuts and burns. Others, including some Noroviruses, can spread through the air. Many other pathogens exist, but the CDC has found these particular strains to be of the greatest concern, especially in settings where food is handled."
Fanaselle says that the Norovirus strains represent a new category for food handlers because they are airborne, rather than foodborne or waterborne. The primary concern is that sick workers will transmit the pathogen through vomit. The department is also concerned with cross-contamination in restaurants. This means of transmission, however, includes a growth period for bacteria that varies depending on many factors, including temperature, dosage and the medium that supports the pathogen.
"The recommended worker protocol, if conducted correctly, can help to reduce the risk of Norovirus transmission," Fanaselle says. "The food code emphasizes the importance of employee health, and it focuses on the four pathogens we consider the most virulent and highly infectious. They include hepatitis A, Salmonella typhi, Shigella species and Shiga toxin-producing E. coli variants, and will soon include Noroviruses. To be in compliance with the food code, employees with symptoms that include fever, sore throat, diarrhea, upset stomach or other signs of intestinal illness should be removed from any contact with food or utensils that touch food. The risk of Norovirus transmission has spurred our department to change the food code to indicate that workers with any of these symptoms not return to the workplace for at least 24 hours from the time that the symptoms disappear completely." Fanaselle says the newly revised food code is expected to be released in spring 2005.
Layers of Safety and Constant Monitoring to Reduce Risks
The food code does more than keep the restaurant industry abreast of new pathogens and what causes them. It also offers systematic advice to operators on the proper handwashing protocol that workers should follow.
Jeanette Lyons spent nearly 30 years as a consumer safety officer for state health departments and for the FDA. Since retiring earlier this year, she has worked as a consultant for AAC Consulting Group Inc.
"Friction on all surfaces of the hands and arms by vigorously rubbing for at least 10 to 15 seconds, followed by thorough rinsing under clean, running warm water is an integral part of the proper handwashing procedure," Lyons said. "Immediately follow this process with thorough drying. Workers who handle food should pay particular attention to areas under the fingernails, as it is believed to be the biggest culprit in the spread of bacteria and viruses."
"Warm water" means that the temperature should be at least 100 degrees Fahrenheit (38 degrees Celsius). Lyons says a nail brush should be kept in a glass of disinfectant liquid at all handwashing stations, and that workers should use it every time they wash. When and how often they should wash is another key factor. The food code dictates that employees should wash their hands after handling any contaminated surfaces or utensils, after using the toilet and after touching raw animal foods. They should wash for no less than 20 seconds, and the longer the better. She recommends workers sing "Happy Birthday" to themselves twice before rinsing.
"The soundest rule is that hands should never come in contact with food," she says. "But that rule is simply not followed. Look at the food shows on television or the morning shows that have food segments. Chefs seem to enjoy touching food in a way that projects an artistic ability in how they arrange it on the plate. It may be an attractive way to arrange food, but it is against everything that food safety experts dictate is safe practice."
Lyons also offers facts on hand sanitizers that will dissolve any myths or misunderstandings. She said that while hand sanitizers are permitted, according to the FDA's standards and codes, regulating agencies and the manufacturer must confer and agree on the effectiveness of every product that makes the claim on its packaging.
"Such products must go through a drug approval process and be approved as a drug," she says. "Manufacturers must prove the product's ability. In short, hand sanitizers that are approved as food-safe products must go through the same process by which food additives are subjected. The larger issue, however, is if increased use of these products enables surviving bacteria to develop a greater resistance because of frequent and consistent exposure to the antibacterial agent."
Wearing gloves is another safety layer being used in some restaurants. Lyons says they are a good idea because they prevent hand-food contact. But gloves also present a set of problems. Many people put on a set of "perceptions" as they put on gloves. It stems from the mentality that we wear gloves to protect ourselves. To effectively reduce the risk of spreading pathogens, gloves must be changed frequently. They should be replaced every time a worker uses the toilet, switches to handling a different food product or touches themselves or their clothing. And, hands should still be washed every time gloves are changed. Gloves are not a substitute for proper hand sanitation.
"Gloves can leak, and when they rupture they usually do around the nail area -- the primary cause of pathogen spreading," Lyons said. "Restaurants who use gloves generally do not use medical-grade products, which are stronger. Another problem is that many people have latex allergies and cannot wear gloves made from the material."
Don't Just Talk the Talk, Walk the Walk
The scientific, medical and regulating communities have done an excellent job of keeping track of pathogens, investigating what causes an outbreak and developing codes that offer the best possible ways to prevent them from spreading. But this knowledge does not always solve the biggest problem: getting workers to follow safe handwashing procedures. Lyons says she gets blank stares when she asks restaurant owners, managers and operators if they have a food safety program that includes proper handwashing protocol, or a policy that dictates workers be removed from food- or utensil-handling functions when they show signs of illness.
"Industry professionals who are interested and concerned about this issue have tried many different ploys to get workers to wash their hands properly and more frequently," she says. "Some I have heard of include a policy that requires workers to refrain from touching food with their bare hands, for example. One restaurant chain used a system where a bell rang every 30 minutes in the food preparation areas indicating that it was time for people to wash their hands. But during their busiest times, people would get frustrated by the bell and ultimately disconnect it. Other chains have used two-colored glove programs. One color is designated for meat handling, for example, and another for fresh produce. One restaurant I conferred with makes prospective workers demonstrate how they wash their hands during the interview process. Some of these systems have worked well, while others have been washed down the drain with the dirty water -- they are just too complicated or inconvenient in a busy restaurant."
Every expert on the topic of pathogen transmission in restaurants agrees that layers of safety include sound training programs, constant reminders and a check system. Combined practices make the best policy for restaurants to reduce the risk of a pathogen outbreak that stems from a worker's unclean hands. They also say that young people tend to forget the good hand hygiene practices their parents taught them as children, while others were simply never taught good hygiene. In either case, it is the responsibility of the restaurant to teach workers the importance of washing their hands, and the way to properly do it -- from the first day the worker is on the job.
It is Only a Matter of Conscious Habit
There is enough information on pathogens available from the USDA and other agencies and organizations for any restaurant, regardless of its size or culture, to develop a handwashing policy and make it a part of their workplace culture. Like any rule, policy or procedure an organization dictates, however, long-term success of a food safety program that includes proper handwashing practices is dependent on leadership setting a good example. Buckhead Colorado Steakhouse (formerly Buckhead Brewery), based in Atlanta, Georgia, is a good paradigm of how leadership buy-in has contributed to the success of such a program. The company has four restaurants in operation, and two in the development stages. Each location has about 90 employees.
"Our handwashing policy was originally developed as a combination of our own standards," says Alan Richardson, vice president of operations. "We did not need a personal incident, or an example set by an outbreak at some other restaurant company. Our attitude is that we are not only serving food -- we are also responsible for our guests' safety."
The company's policy includes a stringent employee orientation, according to Richardson. "Every employee is trained in hand sanitation processes," he says. "Kitchen workers and food handlers receive more extensive training than those who do not handle food, but everyone is trained in our food safety policies. The first thing workers do when they arrive at work is wash their hands. Handwashing posters are placed throughout the handwashing stations, as well as in kitchen areas and server alleys. Wash stations are checked every hour to ensure that the water temperature is accurate, the area is clean and that supplies of detergents, towels and hand sanitizers are ample. Hand sanitizer is an additional level of safety we enforce in our policy."
Every Buckhead Colorado Steakhouse manager is certified in ServSafe food safety training, an educational program offered by the National Restaurant Association. Richardson says that the topic of handwashing and food safety surfaced at one of the company's initial meetings during its formation in 1995, and it has remained a topic of priority for the company since that time.
"We also partner with food vendors who employ ServSafe in their own businesses," he said. "The program requires recertification every five years by taking an extensive food safety course that covers much more than just proper handwashing procedures. Attendees learn about foodborne pathogens, how they spread and how to effectively destroy them. The certification and training programs have aided us in developing our own employee protocol procedure."
Even though the company has never experienced a breakdown in its food safety program, and has never had an incident related to food safety, Richardson says that company leaders know that proper handwashing will always be an issue that necessitates in-depth training and constant reminders.
"Young people especially have to be properly trained and reminded," he says. "It is also imperative to offer training and reminders in all of the languages represented by a company's staff. In our case, for example, we offer the material in Hispanic as well as in English."
Proper Hand Sanitation is About More Than Just Company Success
Proper handwashing practice is about much, much more than protecting your company's bottom line or its reputation -- it is about life or death. Few people know this fact as well as many of those who dedicate a lot of time and energy to STOP.
"My 6-year-old son, Alex, died in 1993 of E. coli O157:H7," says Chicago resident Nancy Donley, president of STOP. "It was decided that the pathogen was in frozen hamburger patties purchased from a grocery store. I also ate the hamburger, and experienced some problems, but I felt like I just had a summer flu. Unlike mine, Alex's immune system was immature. He went from being perfectly fine to suffering a complete breakdown of his internal organs in mere hours."
Today, Donley spends a great deal of her time speaking with experts and legislators in attempts to have more rigorous policy adopted on a federal level.
"We have always taken a strong position in food handler handwashing issues," she says. "The programs we advocate include ServSafe and others that train workers in proper hygiene. Every employee, down to the people who bus tables, should have some sort of training, and they should be told the reasons it is necessary. Despite the many pathogen outbreaks reported, the thousands of illnesses and deaths, many people still do not get it. It is more than a bellyache -- it is deadly."
Ironically, Donley says that those who have the most hands-on work in restaurants have the least training. Beyond monitoring washbasins, which have their own set of litigation risks, proper training and constant reminders are the best protective tools available today. She agrees that training must be offered in languages that every worker will understand.
"We continue to work at an animal level because that is where the root of the problem lies," she says. "But using the safest practices possible to prevent pathogens from spreading from the animal level on -- all the way to when the dish of food is placed in front of the customer -- is imperative to the safety of the public, and for many of our children it is a matter of life or death."
Fanaselle says that every year about 76 million illnesses, 325,000 hospitalizations and 5,000 deaths occur from foodborne pathogens.
"These estimations are published, but the FDA knows they are not accurate," she says. "The real numbers are a great deal higher. Not everyone who becomes ill reports it or goes to a doctor and medical professionals who see ill patients do not always diagnosis the illness properly. Some guess, based on the symptoms, for example. Even fewer have a test done on a fecal sample. We are afraid that the true figures are staggering, and would likely tell us how fortunate we are that many more people have not died from pathogen-related illness."
Create a Culture of Handwashing Awareness
Few folks give as much thought to the importance of handwashing as does Mary Anne Hogue, R.D., FADA, CFSP. A registered dietician and certified food safety professional, Hogue is vice president of food safety services for Steritech Inc., a Charlotte, North Carolina-based sanitation auditing and consulting company. Steritech helps restaurants find problems in their sanitation practices through sophisticated audits, and coaches them to improve practices and conditions. Handwashing figures prominently in maintaining a sanitary house.
Hogue provided the following recommendations and checklists for restaurateurs who hope to create a "culture of awareness," regarding the best handwashing practices. She also provided a valuable checklist (see "Hand Sanitation Checklist" on Page 30) and step-by-step instructions to washing your hands (see "How to Wash Your Hands in Eight Easy Steps" on Page 30).
Adults learn based on 'what's in it for me.' Hogue says that managers need to emphasize to employees that good handwashing habits not only protect customers, but the employees' and their loved ones' health, as well. That equates to fewer missed days of work and school, and fewer visits to the doctor.
Management needs to model behavior. "Each time the manager walks into the food production area he or she needs to wash his or her hands," says Hogue. Don't be stealthy about it. Show the entire staff that you walk the walk.
Make it easy for staff to wash their hands. According to Hogue, it is vital that you maintain a clean and inviting area for handwashing in sinks set aside for that purpose. Ensure that the area is well-stocked with soap and towels.
Think positive reinforcement. Don't just criticize employees when you catch them neglecting to wash their hands properly. Praise them when you catch them doing a good job.
Provide employee orientation. Hogue reminds managers to employ handwashing training, and to make it part of the employee handbook. She also gives high marks to a video training program "Handwashing for Life." Three 90-second video segments teach viewers when to wash, why wash, and how to wash. The techniques are illustrated without language, making it ideal as a training device for workers for whom English is not their first language. (The video is available from Steritech; go to www.steritech.com for more information.)
And don't forget posters; just don't rely on them. They are "often seen but unseen," Hogue says. She also says that some companies have handwashing "Olympics," i.e. competitions for hand cleanliness. It's an entertaining way to bring the subject to the foreground.
Don't treat gloves as a panacea. It's imperative that you wash your hands before putting on gloves, and gloves should be changed as soon as they become contaminated, Hogue says.
Hand Sanitation Checklist -- When Should You Wash Your Hands?
- After using the restroom
- Before handling any food
- After touching any part of your body, including your hair
- After coughing or sneezing
- After eating or drinking
- Between handling raw- and ready-to-eat food
- After handling dirty utensils
Source: Mary Anne Hogue, vice president, Food Safety Services, Steritech Inc.
How to Wash Your Hands in Eight Easy Steps
- Turn the faucet on for hot water.
- Remove towel from paper dispenser.
- Place in your hand a dribble of soap the size of a quarter.
- Wash hands for about 20 seconds.
- Rinse with hot water.
- Dry with paper towel.
- Use towel to turn off the faucet.
- Throw away paper towel.
Source: Mary Anne Hogue, vice president, Food Safety Services, Steritech Inc.
