FDA Food Code 2009: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 2, Management and Personnel
Public Health Reasons / Administrative Guidelines for:
- Chapter 1: Purpose and Definitions
- Chapter 3: Food
- Chapter 4: Equipment, Utensils, and Linens
- Chapter 5: Water, Plumbing, and Waste
- Chapter 6: Physical Facilities
- Chapter 7: Poisonous or Toxic Materials
- Chapter 8: Compliance and Enforcement
Designation of a person in charge during all hours of operations ensures the continuous presence of someone who is responsible for monitoring and managing all food establishment operations and who is authorized to take actions to ensure that the Code's objectives are fulfilled. During the day-to-day operation of a food establishment, a person who is immediately available and knowledgeable in both operational and Code requirements is needed to respond to questions and concerns and to resolve problems.
In cases where a food establishment has several departments on the premises (e.g., a grocery store with deli, seafood, and produce departments) and the regulatory authority has permitted those departments individually as separate food establishments, it may be unnecessary from a food safety standpoint to staff each department with a separate Person in Charge during periods when food is not being prepared, packaged or served. While activities such as moving food products from a refrigerated display case to the walk-in refrigerator, cleaning the floors, or doing inventory when the department is not busy, do take place during these times, a designated Person in Charge for multiple departments or the entire facility can oversee these operations and be ready to take corrective actions if necessary.
The designated person in charge who is knowledgeable about foodborne disease prevention, Hazard Analysis and Critical Control Point (HACCP) principles, and Code requirements is prepared to recognize conditions that may contribute to foodborne illness or that otherwise fail to comply with Code requirements, and to take appropriate preventive and corrective actions.
There are many ways in which the person in charge can demonstrate competency. Many aspects of the food operation itself will reflect the competency of that person. A dialogue with the person in charge during the inspection process will also reveal whether or not that person is enabled by a clear understanding of the Code and its public health principles to follow sound food safety practices and to produce foods that are safe, wholesome, unadulterated, and accurately represented.
The Food Code does not require reporting of uninfected cuts or reporting of covered, protected infected cuts/lesions/boils since no bare hand contact with ready-to-eat (RTE) food is a Code requirement.
2-102.20 Food Protection Manager Certification.
Many food protection manager certification programs have shared a desire to have the food manager certificates they issue universally recognized and accepted by others - especially by the increasing number of regulatory authorities that require food manager certification.
Needed has been a mechanism for regulatory authorities to use in determining which certificates should be considered credible based on which certificate issuing programs meet sound organizational and certification procedures and use defensible processes in their test development and administration.
After a multi-year effort involving a diversity of stakeholder groups, the Conference for Food Protection (CFP) completed work on its Standards for Accreditation of Food Protection Manager Certification Programs. In 2002 the Conference entered into a cooperative agreement with the American National Standards Institute (ANSI) to provide independent third-party evaluation and accreditation of certification bodies determined to be in conformance with these Conference standards. ANSI published its first listing of accredited certifiers in 2003.
The Acting Commissioner of the Food and Drug Administration, in his address before the 2004 biennial meeting of the Conference for Food Protection, commended this Conference achievement and encouraged universal acceptance based on the CFP/ANSI accreditation program.
Distributed at this meeting was the following letter addressed to the Conference Chair and signed by the Director of FDA's Center for Food Safety and Applied Nutrition. The letter puts forth the Agency's basis for its support of universal acceptance of food protection manager certifications.
"The 2004 biennial meeting of the Conference for Food Protection is a fitting occasion for FDA's Center for Food Safety and Applied Nutrition to commend the Conference for its significant achievements in support of State and local food safety programs.
The FDA in a Memorandum of Understanding recognizes the Conference for Food Protection as a voluntary national organization qualified to develop standards to promote food protection. Conference recommendations contribute to improvements in the model FDA Food Code and help jurisdictions justify, adopt and implement its provisions.
Conference mechanisms involving active participation by representatives of diverse stakeholder groups produce consensus standards of the highest quality. An excellent example is the Conference's Standards for Accreditation of Food Protection Manager Certification Programs, and its announcement of the new on-line listing of accredited certifiers of industry food protection managers. Many years in their development, these Conference standards identify the essential components necessary for a credible certification program. Components cover a wide range of requirements such as detailed criteria for exam development and administration, and responsibilities of the certification organization to candidates and the public.
FDA applauds the Conference for this significant achievement, and encourages agencies at all levels of government to accept certificates issued by listed certifiers as meeting their jurisdictions' food safety knowledge and certification requirements. The American National Standards Institute (ANSI) has independently evaluated these certification programs under an agreement with the Conference for Food Protection. Governments and industry widely recognize and respect ANSI as an accrediting organization. ANSI has found certifiers it lists as accredited under "conformity assessment" - "personnel certification accreditation" to conform to the Conference's Standards for Accreditation of Food Protection Manager Certification Programs.*
The Food Code states the person in charge of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness. Section 2-102.11 states that one means by which a person in charge may demonstrate required knowledge of food safety is through certification as a food protection manager by passing an examination that is part of an accredited program.**
FDA encourages food regulatory authorities and others evaluating credentials for food protection managers to recognize the Conference for Food Protection/ANSI means of accrediting certification programs. This procedure provides a means for universal acceptance of individuals who successfully demonstrate knowledge of food safety. The procedure provides officials assurance that food safety certification is based on valid, reliable, and legally defensible criteria. In addition, universal acceptance eliminates the inconvenience and unnecessary expense of repeating training and testing when managers work across jurisdictional boundaries.
FDA, along with State, local, tribal, and other Federal agencies and the food industry, share the responsibility for ensuring that our food supply is safe. It is anticipated that this new Conference for Food Protection/ANSI program will lead to enhanced consumer protection, improve the overall level of food safety, and be an important component of a seamless national food safety system."
* ANSI's "Directory of Accredited Personnel Certification Programs utilizing Conference for Food Protection (CFP) Standards" may be viewed on-line. Select "Accreditation Services" in the menu on the left. Then select "ANSI Accredited Personnel Certification Bodies and Applicants" in the new left-hand menu under the heading "Personnel Certification Accreditation."
** Accredited program does not refer to training functions or educational programs.
2-103.11 Person in Charge.
A primary responsibility of the person in charge is to ensure compliance with Code requirements. Any individual present in areas of a food establishment where food and food-contact items are exposed presents a potential contamination risk. By controlling who is allowed in those areas and when visits are scheduled and by assuring that all authorized persons in the establishment, such as delivery, maintenance and service personnel, and pest control operators, comply with the Code requirements, the person in charge establishes an important barrier to food contamination.
Tours of food preparation areas serve educational and promotional purposes; however, the timing of such visits is critical to food safety. Tours may disrupt standard or routine operational procedures, and the disruption could lead to unsafe food. By scheduling tours during nonpeak hours the opportunities for contamination are reduced.
Food allergy is an increasing food safety and public health issue, affecting approximately 4% of the U.S. population, or twelve million Americans.
Restaurant and retail food service managers need to be aware of the serious nature of food allergies, including allergic reactions, anaphylaxis, and death; to know the eight major food allergens; to understand food allergen ingredient identities and labeling; and to avoid cross-contact during food preparation and service. The 2008 Conference of Food Protection (CFP) passed Issue 2008-III-006 which provided that food allergy awareness should be a food safety training duty of the Person in Charge. Accordingly, the Person in Charge's Duties under paragraph (L) were amended to assure the food safety training of employees includes food allergy awareness in order for them to safely perform duties related to food allergies.
Paragraph (L) "Employees are properly trained in food safety, including food allergy awareness, as it relates to their assigned duties" allows industry to develop and implement operational-specific training programs for food employees. It is not intended to require that all food employees pass a test that is part of an accredited program.
2-2 Employee Health
The purpose of this section of the Food Code is to reduce the likelihood that certain viral and bacterial agents will be transmitted from infected food workers into food. The agents of concern are known to be readily transmissible via food that has been contaminated by ill food workers, and so for that reason, are the primary focus of the Employee Health section of the Food Code. However, there are different levels of risk associated with different levels of clinical illness. The structure of the restrictions and exclusions has, therefore, been designed in a tiered fashion depending on the clinical situation to offer the maximum protection to public health with the minimal disruption to employees and employers.
Four levels of illness or potential illness have been identified with the first level being the highest potential risk to public health and the fourth level being the lowest. The first level relates to employees who have specific symptoms (e.g., vomiting, diarrhea, jaundice) while in the workplace. These symptoms are known to be associated commonly with the agents most likely to be transmitted from infected food workers through contamination of food. The first level also relates to employees who have been diagnosed with typhoid fever or an infection with hepatitis A virus (within 14 days of symptoms). The second level relates to employees who have been diagnosed with the specific agents that are of concern, but who are not exhibiting symptoms of disease because their symptoms have resolved. The third level relates to employees who are diagnosed with the specific agents, but never develop any gastrointestinal symptoms. The fourth level relates to those individuals who are clinically well but who may have been exposed to a listed pathogen and are within the normal incubation period of disease.
The most significant degree of restriction and exclusion applies to the first level of food employee illness. Infected food employees in the first level are likely to be excreting high levels of their infectious pathogen, increasing the chance of transmission to food products, and thus on to those consuming the food. The first level includes food employees who are:
- Experiencing active symptoms of diarrhea or vomiting - with no diagnosis,
- Experiencing jaundice within the last 7 days-- with no diagnosis,
- Diagnosed with typhoid fever,
- Diagnosed with hepatitis A within 7 days of jaundice or 14 days of any symptoms, or
- Experiencing active symptoms of diarrhea or vomiting, and diagnosed with Norovirus, E. coli O157:H7 or other Enterohemorrhagic Escherichia coli (EHEC) or Shiga toxin-producing Escherichia coli (STEC), or Shigella spp. infection.
Diagnosis with typhoid fever or hepatitis A virus is included in level 1 because employees diagnosed with these pathogens are likely to be shedding high levels of the pathogen in their stool without exhibiting gastrointestinal symptoms. Peak levels of hepatitis A viral shedding in the feces typically occurs before symptoms appear. Diarrhea and vomiting are reliable indicators of infection with Norovirus, E. coli O157:H7 or other EHEC, and Shigella spp., but are not typical symptoms of typhoid fever or hepatitis A. For example, employees diagnosed with typhoid fever are more likely to experience constipation, rather than diarrhea. Jaundice is also not always reliable as an indicator of a hepatitis A infection because employees can be infected with hepatitis A virus without experiencing jaundice (anicteric employees).
Maximum protection to public health requires excluding food employees suffering from typhoid fever, hepatitis A virus, or specific gastrointestinal symptoms associated with diseases identified as likely to be transmitted through contamination of food (See section 2-201.12, Tables 2-201.12 #1a and #1b in this Annex). This situation describes the highest level of risk in transmitting pathogens to food, or what we would find in the first level.
Food employees who have been diagnosed with one of the agents of concern, but are not symptomatic because their symptoms have resolved, are still likely to be carrying the infected agent in their intestinal tract. This makes such employees less likely to spread the agent into food than others who are actually symptomatic, but employees diagnosed with one of the agents of concern still pose an elevated threat to public health. For this reason, there are a series of exclusions (if the employees work in facilities serving highly susceptible populations (HSP)) and restrictions (for non-HSP facilities) depending on the agent involved (See section 2-201.12, Table #2). This situation describes the second level of risk in transmitting pathogens to food.
Diagnosed, asymptomatic food employees who never develop symptoms are typically identified during a foodborne illness outbreak investigation through microbiological testing. If infected and asymptomatic employees are not microbiologically tested, they will remain undetected and could therefore extend the duration of a foodborne illness outbreak through continued contamination of food. The Food Code provides restriction or exclusion guidelines for employees that are identified through microbiological testing with an infection from a listed foodborne pathogen, but are otherwise asymptomatic and clinically well (See section 2-201.12, Table #3). The exclusion or restriction guidelines are applied until the identified food employees no longer present a risk for foodborne pathogen transmission. This situation describes the third level of risk in transmitting pathogens to food.
Some food employees or conditional employees may report a possible exposure to an agent. For example, a food employee may have attended a function at which the food employee ate food that was associated with an outbreak of shigellosis, but the employee remains well. Such individuals fall into the category of having had a potential exposure and present a lower risk to public health than someone who is either symptomatic or who has a definitive diagnosis. They present a level of risk to public health that is greater than if they had not had the exposure. The approach taken in the Food Code to food employees who have had a potential exposure is based on the incubation times (time between exposure and the onset of symptoms) of the various agents. The times chosen for restriction are the upper end of the average incubation periods for the specific agents. The reasoning is that this will restrict food employees only up to the time when it is unlikely they will develop symptoms. As a further protection to public health, it is recommended that such exposed food employees pay particular attention to personal hygiene and report the onset of any symptoms (See section 2-201.12, Table #4). This situation describes the fourth level of risk in transmitting pathogens to food.
This structured approach has linked the degree of exclusion and restriction to the degree of risk that an infected food worker will transmit an agent of concern into food. The approach strikes a balance between protecting public health and the needs of the food employee and employer.
The Food Code provisions related to employee health are aimed at removing highly infectious food employees from the work place. They were developed with recognition of the characteristics of the five important pathogens, and of the risk of disease transmission associated with symptomatic and asymptomatic shedders. The provisions also account for the increased risk associated with serving food to HSP's and the need to provide extra protection to those populations.
The Employee Health section was developed and revised with assistance and input from the Centers for Disease Control and Prevention (CDC) and the U.S. Equal Employment Opportunity Commission (EEOC). The exclusion and restriction criteria are based on communicable disease information, as required by the Americans with Disabilities Act of 1990, in the list of infectious and communicable "Diseases Which are Transmitted through the Food Supply" (also available in PDF, 48 kB), published in the Federal Register on November 17, 2008, (Volume 73, Number 222) by the CDC, and from the Control of Communicable Diseases Manual, 18th Ed., David L. Heymann, MD, Editor, by the American Public Health Association, Washington D.C., 2004.
2-201 Infected Food Employees and Conditional Employees Practical Applications of Using Subpart 2-201
The information provided in Subpart 2-201 is designed to assist food establishment managers and regulatory officials in removing infected food employees when they are at greatest risk of transmitting foodborne pathogens to food. Practical applications of the information in Subpart 2-201 by a food establishment manager may involve using Subpart 2-201 as a basis for obtaining information on the health status of food employees and can also be used as a basis in developing and implementing an effective Employee Health Policy. Regulatory officials can benefit by using the information provided below as a basis for determining compliance with Subpart 2-201 during a facility food safety inspection.
The development and effective implementation of an employee health policy based on the provisions in Subpart 2-201 may help to prevent foodborne illness associated with contamination of food by ill or infected food employees. The person in charge and food employees should be familiar with and able to provide the following information through direct dialogue or other means when interviewed by facility managers or regulatory officials. Compliance must be based, however, on first hand observations or information and cannot be based solely on responses from the person in charge to questions regarding hypothetical situations or knowledge of the Food Code. Also, when designing and implementing an employee health policy, the following information should be considered and addressed:
- Does the establishment have an Employee Health Policy? If so, are the food employees aware of the employee health policy, and is it available in written format and readily available for food employees? (Note: A written Employee Health Policy is not a Food Code requirement unless the facility is operating under a pre-approved alternative procedure specified under ¶ 3-301.11(D)).
- Does the establishment require conditional employees and food employees to report certain illnesses, conditions, symptoms, and exposures?
- Are the reporting requirements explained to all employees?
- What are the reporting requirements for conditional employees, food employees, and the food establishment manager?
- Are conditional employees asked if they are experiencing certain symptoms or illnesses upon offer of employment? If so, which symptoms or illnesses?
- If a food employee reports a diagnosis with one of the 5 listed pathogens in the Food Code, what questions are asked of the food employee? (The first question every food manager should ask a food employee who reports diagnosis with a listed pathogen is if the employee is currently having any symptoms.)
- Who does the establishment notify when a food employee reports a diagnosis with one of the listed pathogens?
- What gastrointestinal symptoms would require exclusion of a food employee from the food establishment?
- What history of exposure is a conditional employee or food employee required to report?
- If a food employee reports a gastrointestinal symptom, what criteria are used to allow the employee to return to work?
Responsibilities Symptoms and Diagnosis
2-201.11 Responsibility of the Person in Charge, Food Employees, and Conditional Employees.
Proper management of a food establishment operation begins with employing healthy people and instituting a system of identifying employees who present a risk of transmitting foodborne pathogens to food or to other employees. The person in charge is responsible for ensuring all food employees and conditional employees are knowledgeable and understand their responsibility to report listed symptoms, diagnosis with an illness from a listed pathogen, or exposure to a listed pathogen to the person in charge. The person in charge is also responsible for reporting to the regulatory official if a food employee reports a diagnosis with a listed pathogen.
This reporting requirement is an important component of any food safety program. A food employee who suffers from any of the illnesses or medical symptoms or has a history of exposure to a listed pathogen in this Code may transmit disease through the food being prepared. The person in charge must first be aware that a food employee or conditional employee is suffering from a disease or symptom listed in the Code before steps can be taken to reduce the chance of foodborne illness.
The person in charge may observe some of the symptoms that must be reported. However, food employees and conditional employees share a responsibility for preventing foodborne illness and are obligated to inform the person in charge if they are suffering from any of the listed symptoms, have a history of exposure to one of the listed pathogens, or have been diagnosed with an illness caused by a listed pathogen. Food employees must comply with restrictions or exclusions imposed upon them.
A conditional employee is a potential food employee to whom a job offer has been made, conditional on responses to subsequent medical questions or examinations. A conditional employee becomes a food employee as soon as the employee begins working, even if only on a restricted basis. When a conditional employee reports a listed diagnosis or symptom, the person in charge is responsible for ensuring that the conditional employee is prohibited from becoming a food employee until the criteria for reinstatement of an exclusion are met (as specified under section 2-201.13 of the Food Code). When a symptomatic or diagnosed conditional employee has met the same criteria for reinstatement that apply to an excluded symptomatic or diagnosed food employee (as specified under section 2-201.13 of the Food Code), the conditional employee may then begin working as a food employee.
In order to protect the health of consumers and employees, information concerning the health status of conditional employees and food employees must be disclosed to the person in charge. The symptoms listed in the Code cover the common symptoms experienced by persons suffering from the pathogens identified by CDC as transmissible through food by infected food employees. A food employee suffering from any of the symptoms listed presents an increased risk of transmitting foodborne illness.
The symptoms of vomiting, diarrhea, or jaundice serve as an indication that an individual may be infected with a fecal-oral route pathogen, and is likely to be excreting high levels of the infectious agent. When a food employee is shedding extremely high numbers of a pathogen through the stool or vomitus, there is greater chance of transmitting the pathogen to food products.
Sore throat with fever serves as an indication that the individual may be infected with Streptococcus pyogenes. Streptococcus pyogenes causes a common infection otherwise known as "streptococcal sore throat" or "strep throat." Streptococcal sore throat can spread from contaminated hands to food, which has been the source of explosive streptococcal sore throat outbreaks. Previous foodborne episodes with streptococcus sore throat have occurred in contaminated milk and egg products. Food products can be contaminated by infected food workers hands or from nasal discharges. Untreated individuals in uncomplicated cases can be communicable for 10-21 days, and untreated individuals with purulent discharges may be communicable for weeks or months.
Lesions containing pus that may occur on a food employee's hands, as opposed to such wounds on other parts of the body, represent a direct threat for introducing Staphylococcus aureus into food. Consequently, a double barrier is required to cover hand and wrist lesions. Pustular lesions on the arms are less of a concern when usual food preparation practices are employed and, therefore, a single barrier is allowed. However, if the food preparation practices entail contact of the exposed portion of the arm with food, a barrier equivalent to that required for the hands and wrists would be necessitated. Lesions on other parts of the body need to be covered; but an impermeable bandage is not considered necessary for food safety purposes. Food employees should be aware that hands and fingers that contact pustular lesions on other parts of the body or with the mucous membrane of the nose also pose a direct threat for introducing Staphylococcus aureus into food.
If a food employee has an infected cut and bandages it and puts on a glove, the employee does not have to report the infected cut to the person in charge. However, if the employee does not bandage it, reporting is required.
Title I of the Americans with Disabilities Act of 1990 (ADA)
Title I of the Americans with Disabilities Act of 1990 (ADA) prohibits medical examinations and inquiries as to the existence, nature, or severity of a disability before extending a conditional offer of employment. In order for the permit holder and the person in charge to be in compliance with this particular aspect of the Code and the ADA, a conditional job offer must be made before making inquiries about the applicant's health status.
The ADA also requires that employers provide reasonable accommodation to qualified applicants and employees with disabilities. A reasonable accommodation is a change in the application process, in the way a job is done, or to other parts of the job that enables a person with a disability to have equal employment opportunities. ADA disabilities are serious, long-term conditions. Most people with diseases resulting from the pathogens listed in the Food Code do not have ADA disabilities because these diseases are usually short-term in duration. In addition, the gastrointestinal symptoms listed in the Food Code usually are not long-term and severe enough, in themselves, to be ADA disabilities. Of course, these symptoms may be linked to other conditions that may be serious enough to be ADA disabilities, like Crohn's disease or cancer.
A food employer may exclude any employee under the Food Code upon initially learning that the employee has Salmonella Typhi, or has a gastrointestinal symptom listed in the Food Code. The excluded employee may then ask for an ADA reasonable accommodation instead of the exclusion. In response, the employer's first step should be to ask the employee to establish that the employee is disabled by the disease or symptom (or that the symptom is caused by another ADA disability). If the employee successfully proves that the employee has an ADA disability, then the employer may continue to exclude the employee under the Food Code if:
- there is no reasonable accommodation at work that would eliminate the risk of transmitting the disease while also allowing the employee to work in a food handling position, or
- all reasonable accommodations would pose an undue hardship on the employer's business; and
- there is no vacant position not involving food handling for which the employee is qualified and to which the employee can be reassigned.
Example 1: A food employee working in the café of a department store informs the employer that the employee has been diagnosed with a disease caused by Salmonella Typhi. The employer immediately excludes the employee under the requirements of the Food Code. The employee then establishes that the disease is an ADA disability because it is severe and long-term and the employee requests reasonable accommodation instead of an exclusion. The employer determines that no reasonable accommodation would eliminate the risk of transmitting Salmonella Typhi through food and refuses to remove the exclusion. However, there is a vacant clerical position in another part of the store for which the employee is qualified. Unless the employer can establish that reassigning the employee to this position would be an undue hardship, the employer's failure to make the reassignment instead of continuing the exclusion would be a violation of the ADA.
 Whether or not the employee in question is an individual with an ADA disability, in those jurisdictions where the Code is adopted, Food Code exclusions or restrictions must be removed when requirements for removal under § 2-201.13 of the Code are met.
Example 2: A food employee has diarrhea and is excluded. The employee establishes that the diarrhea is caused by Crohn's disease. This employee also establishes a serious longstanding history of Crohn's disease and is an individual with an ADA disability. Crohn's disease is not a communicable disease and cannot be transmitted through food. No reasonable accommodation is needed to eliminate the risk of transmitting the disease through the food supply, so the Food Code exclusion should be removed. Of course, the Food Code's provisions on personal cleanliness for hands and arms apply as usual, requiring employees to clean hands and exposed portions of arms after using the toilet room and in other specified circumstances (Subpart 2-301).
Somewhat different rules apply to conditional employees. If a conditional employee reports a disease or symptom listed in the Food Code and shows that the disease or symptom makes the conditional employee an individual with an ADA disability, the employer may withdraw the job offer only if:
- The job involves food handling; and
- The employer determines that either there is no reasonable accommodation that would eliminate the risk of transmitting the disease through food, or any such accommodation would be an undue hardship to the business.
- There is no need to offer the conditional employee a vacant position not involving food handling as a reasonable accommodation.
It should be noted that the information provided here about the ADA is intended to alert employers to the existence of ADA and related CFR requirements. For a comprehensive understanding of the ADA and its implications, consult the references listed in Annex 2 that relate to this section of the Code or contact the U. S. Equal Employment Opportunity Commission. For detailed information about the interaction between the FDA Food Code and the ADA, see the Equal Employment Opportunity Commission's How to Comply with the Americans with Disabilities Act: A Guide for Restaurants and Other Food Service Employers, or Summary How to Comply with the Americans with Disabilities Act: A Guide for Restaurants and Other Food Service Employers for detailed information about the interaction between the FDA Food Code and the ADA.
The information required from applicants and food employees is designed to identify employees who may be suffering from a disease that can be transmitted through food. It is the responsibility of the permit holder to convey to applicants and employees the importance of notifying the person in charge of changes in their health status. Once notified, the person in charge can take action to prevent the likelihood of the transmission of foodborne illness. Applicants, to whom a conditional offer of employment is extended, and food employees are required to report their specific history of exposure, medical symptoms, and previous illnesses. The symptoms listed may be indicative of a disease that is transmitted through the food supply by infected food employees.
As required by the ADA, the CDC published in the Federal Register November 17, 2008, (Volume 73, Number 222) a list of infectious and communicable diseases that are transmitted through food. The CDC updates the list annually. See "List of Infectious and Communicable Diseases which are Transmitted through the Food Supply". The list is divided into two parts: pathogens often transmitted and pathogens occasionally transmitted by infected persons who handle food.
The following Lists summarize the CDC list by comparing the common symptoms of each pathogen. Symptoms may include diarrhea, fever, vomiting, jaundice, and sore throat with fever. The CDC has no evidence that the HIV virus is transmissible via food. Therefore, a food employee positive for the HIV virus is not of concern unless suffering secondary illness listed below. The following Lists include all enterohemorrhagic or Shiga toxin-producing E. coli likely to occur in foods in the United States.
|2. Hepatitis A virus||-||F||-||J||-|
|4. Shigella species||D||F||V||-||-|
|5. Staphylococcus aureus||D||-||V||-||-|
|6. Streptococcus pyogenes||-||F||-||-||S|
|1. Campylobacter jejuni||D||F||V||-||-|
|2. Cryptosporidium parvum||D||-||-||-||-|
|3. Entamoeba histolytica||D||F||-||-||-|
|4. Enterohemorrhagic Escherichia coli||D||-||-||-||-|
|5. Enterotoxigenic Escherichia coli||D||-||V||-||-|
|6. Giardia lamblia||D||-||-||-||-|
|7. Non-typhoidal Salmonella||D||F||V||-||-|
|8. Taenia solium||-||-||-||-||-|
|9. Vibrio cholerae 01||D||-||V||-||-|
|10. Yersinia enterocolitica||D||F||V||-||-|
The 5 Listed Pathogens:
The CDC has designated the 5 organisms listed in the Food Code as having high infectivity via contamination of food by infected food employees. This designation is based on the number of confirmed cases reported that involved food employees infected with one of these organisms and/ or the severity of the medical consequences to those who become ill.
The following is taken from information provided in the 18th Edition of Control of Communicable Diseases Manual, the CDC website, and the FDA Bad Bug Book, and is provided as background information on pathogen virulence, infectivity, and common symptoms exhibited with infection of each of the 5 listed pathogens.
Noroviruses (genus Norovirus, family Caliciviridae) are a group of small (27-40nm), round structured, single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans. Norovirus has also been commonly known as "Norwalk-like virus," "Small Round-structured Virus," and "Winter Vomiting Disease."
The CDC estimates that Norovirus is the leading cause of foodborne illness in the United States. Transmission of Norovirus has been shown to occur most commonly through the fecal oral route, with contaminated food identified as a common vehicle of transmission. Exclusion of food employees exhibiting or reporting diarrhea symptoms is an essential intervention in controlling the transmission of Norovirus from infected food employees' hands to RTE food items. Norovirus also has a high secondary attack rate (> 50%) via person-to-person contact.
Norovirus has also been reported to cause infection by airborne transmission when individuals are in close physical proximity to an infected individual vomiting in the facility. Therefore an infected individual vomiting in a food facility increases the risk of infecting employees and consumers. Foodborne illness outbreaks have occurred from consumers vomiting in the dining room, or employees vomiting on the premises. Removing food employees exhibiting or reporting vomiting symptoms from the food facility protects consumers and fellow workers from infection with Norovirus.
Incubation Period: Generally between 24 and 48 hours (median in outbreaks 33 to 36 hours), but cases can occur within 12 hours of exposure.
Symptoms and Complications: Acute-onset explosive (or projectile) vomiting, watery non-bloody diarrhea with abdominal cramps, nausea, and occasionally, a low grade fever. Symptoms usually last 24 to 60 hours. Vomiting is more common in children. Recovery is usually complete and there is no evidence of any serious long-term sequelae. Among the young and the elderly, dehydration is a common complication. There is no long-term immunity to Norovirus and individuals may be repeatedly infected throughout their lifetimes. There is no specific therapy for viral gastroenteritis. Symptomatic therapy consists of replacement of fluid loss by the administration of liquids orally, and in rare instances, through parenteral intravenous fluid therapy. Earlier feeding studies conducted on Norovirus have found that as many as 30% of individuals infected with Norovirus are asymptomatic.
Infectivity: Noroviruses are highly contagious, and it is thought that an inoculum of as few as 10 viral particles may be sufficient to infect an individual. Although pre-symptomatic shedding may occur, shedding usually begins with onset of symptoms and may continue for 2 weeks after recovery. However the degree of infectivity of prolonged shedding has not been determined. Norovirus is shed at high levels in the stool: 105 - 107/g or more.
Salmonella enterica subspecies enterica serovar Typhi (commonly S. Typhi) causes a systemic bacterial disease, with humans as the only host. This disease is relatively rare in the United States, with fewer than 500 sporadic cases occurring annually in the U.S. Worldwide, the annual estimated incidence of Typhoid fever is about 17 million cases with approximately 600,000 deaths. Currently, most cases of S. Typhi in industrialized nations are imported into the country from developing countries. Antibiotic-resistant strains have become prevalent in several areas of the world.
Incubation period: Depends on inoculum size and on host factors: from 3 days to over 60 days, with a usual range of 8-14 days.
Symptoms: Insidious onset of sustained fever, marked headache, malaise, anorexia, relative bradycardia, splenomegaly, and nonproductive cough in the early stage of the illness, rose spots on the trunk in 25% of white skinned patients and constipation more often than diarrhea in adults. The illness varies from mild illness with low-grade fever to severe clinical disease with abdominal discomfort and multiple complications.
Infectivity: The minimal infectious dose is estimated to be less than 1000 bacterial cells. An individual infected with S. Typhi is infectious as long as the bacilli appear in the excreta, usually from the first week throughout the convalescence; variable thereafter. About 10% of untreated typhoid fever patients will discharge bacilli for 3 months after onset of symptoms, and 2%-5% become permanent carriers; fewer persons affected with paratyphoid organisms may become permanent gallbladder carriers.
Enterohemorrhagic or Shiga Toxin-Producing Escherichia Coli
E. coli O157:H7 is the most commonly identified strain of Enterohemorrhagic Escherichia coli (EHEC) or Shiga toxin-producing Escherichia coli (STEC) as a cause of foodborne illness in the United States. E. coli O157:H7 is a zoonotic disease derived from cattle and other ruminants. However, E. coli O157:H7 also readily transmits from person-to-person, so contaminated raw ingredients and ill food employees both can be sources of foodborne disease. Other EHEC or STEC serotypes have been identified as a source of foodborne illness in the United States, however not as frequently as E. coli O157:H7. The other serogroups most commonly implicated as a cause of foodborne illness in the United States are 026, 0111, 0103, 045, and 0121.
The Food Code definition of STEC covers all E. coli identified in clinical laboratories that produce Shiga toxins. Nearly 200 O:H combinations of E. coli have been shown to produce Shiga toxins. The Food Code definition includes all STEC, including those that have not been specifically implicated in human disease such as hemorrhagic colitis (i.e., bloody diarrhea) or hemolytic uremic syndrome (HUS). A subset of STEC that has the capacity to both produce Shiga toxin and cause "attaching and effacing" lesions in the intestine is classified as "enterohemorrhagic" (EHEC). EHEC E. coli cause hemorrhagic colitis, meaning bleeding enterically or bleeding from the intestine. Infections with EHEC may be asymptomatic but are classically associated with bloody diarrhea (hemorrhagic colitis) and hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). Virtually all human isolates of E. coli O157:H7 seotypes are EHEC.
Incubation period: From 2-10 days, with a median of 3-4 days.
Symptoms: The illness is characterized by severe cramping (abdominal pain) and diarrhea with a range from mild and nonbloody to stools that are virtually all blood. Occasionally vomiting occurs. Some individuals exhibit watery diarrhea only. Lack of fever in most patients can help to differentiate this infection from other enteric pathogens. About 8% of individuals with E. coli O157:H7 diarrhea progress to HUS. This rate varies for other serotypes of Enterohemorrhagic E. coli.
Infectivity: The infectious dose is for example E. coli O157:H7 can be as low as 10 bacterial cells. Children under 5 years old are most frequently diagnosed with infection and are at greatest risk of developing HUS. The elderly also experience a greater risk of complications. The duration of excretion of Enterohemorrhagic E. coli in the stool is typically 1 week or less in adults, but can be up to 3 weeks in one-third of infected children.
Causes an acute bacterial disease, known as shigellosis, and primarily occurs in humans, but also occurs in other primates such as monkeys and chimpanzees. An estimated 300,000 cases of shigellosis occur annually in the U.S. Shigella spp. consist of 4 species or serogroups, including S. flexneri, S. boydii, S. sonnei, and S. dysenteriae; which all differ in geographical distribution and pathogenicity. Shigella spp. are highly infectious and highly virulent. Outbreaks occur in overcrowding conditions, where personal hygiene is poor, including in institutions, such as prisons, mental hospitals, day care centers, and refugee camps, and also among men who have sex with men. Water and RTE foods contaminated by feces, frequently from food workers' hands, are common causes of disease transmission. Multidrug-resistant Shigella (including S. dysenteriae 1) have appeared worldwide. Concern over increasing antimicrobial resistance has led to reduced use of antimicrobial therapy in treating shigellosis.
Incubation period: Usually 1-3 days, but ranges from 12 to 96 hours, and up to 1 week for S. dysenteriae 1.
Symptoms and Complications: Abdominal pain, diarrhea, fever, nausea, and sometimes vomiting, tenesmus, toxaemia, and cramps. The stools typically contain blood, pus, or mucus resulting from mucosal ulcerations. The illness is usually self-limited, with an average duration of 4-7 days. Infections are also associated with rectal bleeding, drastic dehydration, and convulsions in young children. The fatality rate for Shigella dysenteriae 1 may be as high as 20% among hospitalized cases. Other complications can also occur, such as Reiter's disease, reactive arthritis, intestinal perforation, and hemolytic uremic syndrome.
Infectivity: The infectious dose for humans is low, with as few as 10 bacterial cells depending on age and condition of the host. Infectivity occurs during acute infection and until the infectious agent is no longer present in feces, usually within 4 weeks after illness. Asymptomatic carriers may transmit infection; rarely, the carrier state may persist for months or longer.
HEPATITIS A VIRUS
Hepatitis A virus (HAV) is a 27-nanometer picornavirus (positive strand RNA, non-enveloped virus). The hepatitis A virus has been classified as a member of the family Picornaviridae. The exact pathogenesis of HAV infection is not understood, but the virus appears to invade from the intestinal tract and is subsequently transported to the liver. The hepatocytes are the site of viral replication and the virus is thought to be shed via the bile.
HAV is most commonly spread by the fecal-oral route through person-to-person contact. Risk factors for reported cases of hepatitis A include personal or sexual contact with another case, illegal drug use, homosexual male sex contact, and travel to an endemic country. Common source outbreaks also can occur through ingestion of water or food that has fecal contamination. However, the source of infection is not identified for approximately 50% of reported cases.
HAV infection is endemic in developing countries, and less common in industrialized countries with good environmental sanitation and hygienic practices. In the developing world, nearly all HAV infections occur in childhood and are asymptomatic or cause a mild illness. As a result, hepatitis A (symptomatic infection with jaundice) is rarely seen in the developing world. More than 90% of adults born in many developing countries are seropositive.
Children play an important role in the transmission of HAV and serve as a source of infection for others, because most children have asymptomatic infections or mild, unrecognized HAV infections. In the United States, the disease is most common among school-aged children and young adults. After correction for under-reporting and undiagnosed infections, an estimated 61,000 HAV infections (includes cases of hepatitis A as well as asymptomatic infections) occurred in 2003.
HAV Immunization: Immune globulin can be used to provide passive pre-exposure immunoprophylaxis against hepatitis A. Protection is immediately conferred to an exposed individual following administration of IG, and immunity is provided for 3-5 months following inoculation. IG is effective in preventing HAV infection when given as post-exposure immunoprophylaxis, if given within 14 days of exposure. When a food service worker with hepatitis A is identified, IG is often given to co-workers. Active immunoprophylaxis using hepatitis A vaccine (a formalin-inactivated, attenuated strain of HAV) has been shown to provide immunity in > 95% of those immunized, with minimal adverse reactions. Hepatitis A vaccination of food workers has been advocated, but has not been shown to be cost-effective and generally is not recommended in the United States, although it may be appropriate in some communities.
Incubation period: Average 28-30 days (range 15-50 days).
Symptoms and Complications: Illness usually begins with symptoms such as nausea/ vomiting, diarrhea, abdominal pain, fever, headache, and/or fatigue. Jaundice, dark urine or light colored stools might be present at onset, or follow illness symptoms within a few days. HAV infection of older children and adults is more likely to cause clinical illness with jaundice (i.e., hepatitis A); onset of illness is usually abrupt. In young adults, 76-97% have symptoms and 40-70% are jaundiced. Jaundice generally occurs 5-7 days after the onset of gastrointestinal symptoms. For asymptomatic infections, evidence of hepatitis may be detectable only through laboratory tests of liver infections such as alanine aminotransferase (ALT) tests. The disease varies in severity from a mild illness to a fulminant hepatitis, ranging from 1-2 weeks to several months in duration. In up to 10-15% of the reported cases, prolonged, relapsing hepatitis for up to 6 months occurs. The degree of severity often increases with age; however, most cases result in complete recovery, without sequelae or recurrence. The reported case fatality rate is 0.1% - 0.3% and can reach 1.8% for adults over 50 years old.
Diagnosis: Diagnosis of HAV infection requires specific serological testing for IgM anti-HAV. IgM anti-HAV becomes undetectectable within 6 months of illness onset for most persons; however, some persons can remain IgM anti-HAV positive for years after acute infection. Total anti-HAV (the only other licensed serologic test) can be detected during acute infection but remains positive after recovery and for the remainder of the person's life.
Infectivity: Evidence indicates maximum infectivity during the latter half of the incubation period, continuing for a few days after onset of jaundice. Most cases are probably noninfectious after the first week of jaundice. Chronic shedding of HAV in feces has not been reported. HAV is shed at peak levels in the feces, one to two weeks before onset of symptoms, and shedding diminishes rapidly after liver dysfunction or symptoms appear. Liver dysfunction or symptoms occur at the same time circulating antibodies to HAV first appear. Immunity after infection probably lasts for life; immunity after vaccination is estimated to last for at least 20 years.
Reporting History of Exposure:
The reporting requirements for history of exposure are designed to identify employees who may be incubating an infection due to Norovirus, Shigella spp., E. coli O157:H7 or other EHEC/STEC, typhoid fever, or HAV.
Which employees who report exposure are restricted?
- Employees who work in a food establishment serving a highly susceptible population (HSP) facility.
What constitutes exposure?
- Consuming a food that caused illness in another consumer due to infection with Norovirus, Shigella spp., E. coli O157:H7 or other EHEC/STEC, typhoid fever, or HAV.
- Attending an event or working in a setting where there is a known disease outbreak.
- Close contact with a household member who is ill and is diagnosed with a listed pathogen.
Why are other guidelines provided, in addition to restriction for employees serving an HSP who report exposure to hepatitis A virus?
- Employees who have had a hepatitis A illness in the past are most likely protected from infection by life-time immunity to hepatitis A infection.
- Immunity developed through immunization or IgG inoculation prevents hepatitis A infection in exposed employees.
- Our standard definition of HSP doesn't apply very well to HAV. Children under 6 years old who become infected with HAV are generally asymptomatic, and while a higher proportion of susceptible elderly who become infected have serious illness, most institutionalized elderly are protected from HAV by prior infection.
What is the period of restriction?
- The period of restriction begins with the most recent time of foodborne or household member exposure and lasts for the usual incubation period of the pathogen as defined in the Control of Communicable Diseases Manual. This is the time that the employee is most likely to begin shedding the pathogen.
- For Norovirus, 48 hours after the most recent exposure
- For Shigella spp., 3 days after the most recent exposure
- For E. coli O157:H7 or other EHEC/STEC, 3 days after the most recent exposure
- For typhoid fever (S. Typhi), 14 days after the most recent exposure
- For HAV, 30 days after the most recent exposure
What is the period of restriction when exposed to a diagnosed, ill household member?
- While the household member is symptomatic with an infection due to Norovirus, Shigella spp., E coli O157:H7 or other EHEC/STEC, typhoid fever (S. Typhi) or HAV;
- Plus during the usual incubation period of the pathogen of concern:
- For Norovirus, symptomatic period plus 48 hours
- For Shigella spp., symptomatic period plus 3 days
- For E. coli O157:H7 or other EHEC/STEC, symptomatic period plus 3 days
- For typhoid fever (S. Typhi), symptomatic period plus 14 days
- For HAV, onset of jaundice plus 30 days
What is the appropriate response to a report of exposure to other food employees?
- Employees who report a history of exposure but who do not work in a HSP facility should be reminded of the requirements for reporting illness, avoidance of bare hand contact with RTE foods, and proper hand washing and personal hygiene.
2-201.12 Exclusions and Restrictions.
Refer to public health reasons for § 2-201.11 for actions to take with conditional employees.
It is necessary to exclude food employees symptomatic with diarrhea, vomiting, or jaundice, or suffering from a disease likely to be transmitted through contamination of food, because of the increased risk that the food being prepared will be contaminated such as with a pathogenic microorganism. However, if the food employee is suffering from vomiting or diarrhea symptoms, and the condition is from a non-infectious condition, Crohn's disease or an illness during early stages of a pregnancy, the risk of transmitting a pathogenic microorganism is minimal. In this case, the food employee may remain working in a full capacity if they can substantiate that the symptom is from a noninfectious condition. The food employee can substantiate this through providing to the person in charge medical documentation or other documentation proving that the symptom is from a noninfectious condition.
Because of the high infectivity (ability to invade and multiply) and/ or virulence (ability to produce severe disease), of typhoid fever (Salmonella Typhi) and hepatitis A virus, a food employee diagnosed with an active case of illness caused by either of these two pathogens, whether asymptomatic or symptomatic, must be excluded from food establishments. The exclusion is based on the high infectivity, and/or the severe medical consequences to individuals infected with these organisms. A food employee diagnosed with an active case of illness caused by Norovirus, Shigella spp., or E. coli O157:H7 or other EHEC/STEC, is excluded if exhibiting symptoms of vomiting and diarrhea, and then allowed to work as the level of risk of pathogen transmission decreases (See section 2-201.12, Tables #1b, #2 and #3).
The degree of risk for a food employee or conditional employee who is diagnosed with an infection but asymptomatic with regard to symptoms, to transmit a foodborne pathogen decreases with the resolution of symptoms. This risk decreases even further for those employees that are diagnosed with a listed pathogen, but never developed symptoms. The decrease in risk is taken under consideration when excluding and restricting diagnosed food employees and results in a slight difference in the way food employees diagnosed with Norovirus, but asymptomatic with respect to gastrointestinal symptoms are handled (See section 2-201.12, Table #2).
2-201.11 / 2-201.12 Decision Tree 1.
When to Exclude or Restrict a Food Employee Who Reports a Symptom and
When to Exclude a Food Employee Who Reports a Diagnosis with Symptoms Under the Food Code
Listed Symptoms for Reporting: (V) Vomiting; (J) Jaundice; (D) Diarrhea; (ST with F) Sore Throat with Fever; (HSP) Highly Susceptible Population; (Gen. Pop.) General Population
2-201.11 / 2-201.12 Decision Tree 2.
When to Exclude or Restrict a Food Employee Who is Asymptomatic and Reports a Listed Diagnosis and When to Restrict a Food Employee Who Reports a Listed Exposure Under the Food Code
(HSP) Highly Susceptible Population; (Gen. Pop.) General Population
|Symptom||EXCLUSION/ OR RESTRICTION||Removing Symptomatic Food Employees from Exclusion or Restriction||RA Approval Needed to Return to Work?|
|Facilities Serving an HSP||Facilities Not serving an HSP|
|When the excluded food employee has been asymptomatic for at least 24 hours or provides medical documentation 2-201.13(A)(1).|
Exceptions: If diagnosed with Norovirus, Shigella spp., E. coli O157:H7 or other EHEC/STEC, HAV, or typhoid fever (S. Typhi) (see Tables 1b & 2).
|No if not diagnosed|
|When the excluded food employee has been asymptomatic for at least 24 hours or provides medical documentation 2-201.13(A).|
Exceptions: If Diagnosed with Norovirus, E. coli O157:H7 or other EHEC/STEC, HAV, or S. Typhi (see Tables 1b & 2).
|No if not diagnosed|
|Jaundice||exclude2-201.12(B)(1) if the onset occurred within the last 7 days||exclude2-201.12(B)(1) if the onset occurred within the last 7 days||When approval is obtained from the RA 2-201.13 (B), and: ||Yes|
|Sore Throat with Fever||EXCLUDE|
|When food employee provides written medical documentation 201.13(G) (1)-(3).||No|
|Infected wound or pustular boil||RESTRICT|
|RESTRICT 2-201.12(H)||When the infected wound or boil is properly covered 2-201.13(H)(1)-(3).||No|
- Food employees and conditional employees shall report symptoms immediately to the person in charge.
- The person in charge shall prohibit a conditional employee who reports a listed symptom from becoming a food employee until meeting the criteria listed in section 2-201.13 of the Food Code,for reinstatement of a symptomatic food employee.
RA = Regulatory Authority
EHEC/STEC = Enterohemorrhagic, or Shiga toxin-producing Escherichia coli
HAV = Hepatitis A virus
HSP = Highly Susceptible Population
|Diagnosis||EXCLUSION Facilities Serving an HSP or Not Serving an HSP||Removing Diagnosed, Symptomatic Food Employees from Exclusion||RA Approval Needed to Return to Work?|
|Hepatitis A virus||EXCLUDE if within 14 days of any symptom, or within 7 days of jaundice 2-201.12(B)(2)||When approval is obtained from the RA 2-201.13(B), and: ||Yes|
|Typhoid Fever (S. Typhi)||EXCLUDE|
|When approval is obtained from the RA 2-201.13(C)(1), and: ||Yes|
|E. coli O157:H7 or other EHEC/ STEC||EXCLUDE Based on vomiting or diarrhea symptoms, under 2-201.12(A)(2)||Yes to return to an HSP or to return unrestricted; not required to work on a restricted basis in a non-HSP facility|
|Norovirus||EXCLUDE Based on vomiting or diarrhea symptoms, under 2-201.12(A)(2)||Yes to return to an HSP or to return unrestricted; not required to work on a restricted basis in a non-HSP facility|
|Shigella spp.||EXCLUDE Based on vomiting or diarrhea symptoms, under 2-201.12(A)(2)||Yes to return to an HSP or to return unrestricted; not required to work on a restricted basis in a non-HSP facility|
- Food employees and conditional employees shall report a listed Diagnosis with symptoms immediately to the person in charge.
- The person in charge shall notify the RA when a food employee is jaundiced or reports a listed diagnosis.
- The person in charge shall prohibit a conditional employee who reports a listed diagnosis with symptoms from becoming a food employee until meeting the criteria listed in section 2-201.13 of the Food Code, for reinstatement of a diagnosed, symptomatic food employee.
|Pathogen Diagnosis||Facilities Serving an HSP||Facilities Not Serving an HSP||Removing Diagnosed Food Employees with Resolved Symptoms from Exclusion or Restriction||RA Approval Required to Return to Work?|
|Typhoid fever (S. Typhi) including previous illness with S. Typhi (see 2-201.11(A)(3))||EXCLUDE|
|When approval is obtained from the RA 2-201.13(C)(1), and: ||Yes|
|E. coli O157:H7 or other EHEC/ STEC||EXCLUDE|
|Hepatitis A virus||EXCLUDE if within 14 days of any symptom, or within 7 days of jaundice 2-201.12(B)(2)||EXCLUDE if within 14 days of any symptom, or within 7 days of jaundice 2-201.12(B)(2)||When approval is obtained from the RA 2-201.13(B), and: ||Yes|
- Food employees and conditional employees shall report a listed diagnosis immediately to the person in charge.
- The person in charge shall notify the RA when a food employee reports a listed diagnosis.
- The person in charge shall prohibit a conditional employee who reports a listed diagnosis from becoming a food employee until meeting the criteria listed in section 2-201.13 of the Food Code, for reinstatement of a diagnosed food employee.
|Pathogen Diagnosis||Facilities Serving an HSP||Facilities Not Serving an HSP||Removing Diagnosed Food Employees Who Never Develop Gastrointestinal Symptoms from Exclusion or Restriction||RA Approval Required to Return to Work?|
|Typhoid Fever (S. Typhi) including previous illness with S. Typhi (see 2-201.11 (A)(3))||EXCLUDE|
|When approval is obtained from the RA 2-201.13(C)(1), and: Food employee provides medical documentation, specifying that the food employee is free of a S. Typhi infection 2-201.13(C)(2).||Yes|
|Remains excluded or restricted until approval is obtained from the RA, and: |
|Norovirus||EXCLUDE 2-201.12(D)(1)||RESTRICT 2-201.12(D)(2)||Remains excluded or restricted until approval is obtained from the RA 2-201.13(D), and ||Yes to return to an HSP or to return unrestricted; Not required to work on a restricted basis in a non-HSP facility|
|E. coli O157:H7 or other EHEC/ STEC||EXCLUDE 2-201.12(F)(1)||RESTRICT|
|Remains excluded or restricted until approval is obtained from the RA 2-201.13(F), and: ||Yes to return to HSP or to return unrestricted; Not required to work on a restricted basis in a non-HSP facility|
|Hepatitis A virus||EXCLUDE 2-201.12(B)(3)||EXCLUDE 2-201.12(B)(3)||When approval is obtained from the RA 2-201.13(B), and ||Yes|
- Food employees and conditional employees shall report a listed diagnosis immediately to the person in charge.
- The person in charge shall notify the RA when a food employee reports a listed diagnosis.
- The person in charge shall prohibit a conditional employee who reports a listed diagnosis from becoming a food employee until meeting the criteria listed in section 2-201.13 of the Food Code, for reinstatement of a diagnosed food employee.
RA = Regulatory Authority
EHEC/STEC = Enterohemorrhagic, or Shiga toxin-producing Escherichia coli
HAV = Hepatitis A virus
HSP = Highly Susceptible
|Pathogen Diagnosis||Facilities Serving an HSP||Facilities Not Serving an HSP||When Can the Restricted Food Employee Return to Work?||RA Approval Needed?|
|Typhoid Fever (S. Typhi)||RESTRICT|
|Educate food employee on symptoms to watch for and ensure compliance with GHP, handwashing and no BHC with RTE foods.||2-201.13(I)(3)When 14 calendar days have passed since the last exposure, or more than 14 days has passed since the food employee's household contact became asymptomatic.||No|
|Shigella spp.||RESTRICT 2-201.12(I)||Educate food employee on symptoms to watch for and ensure compliance with GHP, handwashing and no BHC with RTE foods.||2-201.13(I)(2)When more than 3 calendar days have passed since the last exposure, or more than 3 days have passed since the food employee's household contact became asymptomatic.||No|
|Norovirus||RESTRICT 2-201.12(I)||Educate food employee on symptoms to watch for and ensure compliance with GHP, handwashing and no BHC with RTE foods.||2-201.13(I)(1)When more than 48 hours have passed since the last exposure, or more than 48 hours has passed since the food employee's household contact became asymptomatic.||No|
|E. coli O157:H7 or other EHEC/ STEC||RESTRICT 2-201.12(I)||2-201.13(I)(2)When more than 3 calendar days have passed since the last exposure, or more than 3 calendar days has passed since the food employee's household contact became asymptomatic.||No|
|Hepatitis A virus||RESTRICT 2-201.12(I)||2-201.13(I)(4)When any of the following conditions is met: ||No|
- Food employees and conditional employees shall report a listed exposure to the person in charge.
- The person in charge shall prohibit a conditional employee who reports a listed exposure from becoming a food employee in a facility serving an HSP until meeting the criteria listed in section 2-201.13 of the Food Code, for reinstatement of an exposed food employee.
- The person in charge shall reinforce and ensure compliance with good hygienic practices, symptom reporting requirements, proper handwashing and no BHC with RTE foods for all food employees that report a listed exposure.
2-201.12 Exclusion and Restrictions (continued)
Restrictions and exclusions vary according to the population served because highly susceptible populations have increased vulnerability to foodborne illness. For example, foodborne illness in a healthy individual may be manifested by mild flu-like symptoms. The same foodborne illness may have serious medical consequences in immunocompromised individuals. This point is reinforced by statistics pertaining to deaths associated with foodborne illness caused by Salmonella Enteritidis. Over 70% of the deaths in outbreaks attributed to this organism occurred among individuals who for one reason or another were immunocompromised. This is why the restrictions and exclusions listed in the Code are especially stringent for food employees serving highly susceptible populations.
Periodic testing of food employees for the presence of diseases transmissible through food is not cost effective or reliable. Therefore, restriction and exclusion provisions are triggered by the active gastrointestinal symptoms, followed by diagnosis and history of exposure.
The history of exposure that must be reported applies only to the 5 organisms listed.
Upon being notified of the history of exposure, the person in charge should immediately:
- Discuss the traditional modes of transmission of fecal-oral route pathogens.
- Advise the food employee to observe good hygienic practices both at home and at work. This includes a discussion of proper handwashing, as described in the Code, after going to the bathroom, changing diapers, or handling stool-soiled material.
- Review the symptoms listed in the Code that require immediate exclusion from the food establishment.
- Remind food employees of their responsibility as specified in the Code to inform the person in charge immediately upon the onset of any of the symptoms listed in the Code.
- Ensure that the food employee stops work immediately if any of the symptoms described in the Code develop and reports to the person in charge.
A restricted food employee may work in an area of the food establishment that houses packaged food, wrapped single-service or single-use articles, or soiled food equipment or utensils. Examples of activities that a restricted person might do include working at the cash register, seating patrons, bussing tables, stocking canned or other packaged foods, or working in a non-food cleaning or maintenance capacity consistent with the criteria in the definition of the term "restricted." A food employee who is restricted from working in one food establishment may not work in an unrestricted capacity in another food establishment, but could work unrestricted in another retail store that is not a food establishment. A restricted food employee may enter a food establishment as a consumer.
An excluded individual may not work as a food employee on the premises of any food establishment.
2-201.13 Removal of Exclusions and Restrictions.
Food employees diagnosed with Norovirus, hepatitis A virus, Shigella spp., E. coli O157:H7 or other EHEC, and symptomatic with diarrhea, vomiting, or jaundice, are excluded under subparagraph 2-201.12 (A)(2) or 2-201.12(B)(2). However these symptomatic, diagnosed food employees differ from symptomatic, undiagnosed food employees in the requirements that must be met before returning to work in a full capacity after symptoms resolve.
The person in charge may allow undiagnosed food employees who are initially symptomatic and whose symptoms have resolved to return to work in a full capacity 24 hours after symptoms resolve.
However, diagnosis with a listed pathogen invokes additional requirements before the person in charge may allow diagnosed food employees to return to work in full capacity.
Asymptomatic food employees diagnosed with Norovirus, Shigella spp., E. coli O157:H7 or other EHEC may not return to work in a full capacity for at least 24 hours after symptoms resolve. The person in charge shall only allow these food employees to work on a restricted basis 24 hours after symptoms resolve and they shall only allow this if not in a food establishment that serves a highly susceptible population. These restricted food employees remain restricted until they are medically cleared or otherwise meet the criteria for removal from restriction as specified under subparagraphs 2-201.13(D) (1)-(2); 2-201.13(E)(1)-(2); or 2-201.13(F)(1)-(2).
In a food establishment that serves a highly susceptible population, food employees who are diagnosed with Norovirus, Shigella spp., E. coli O157:H7 or other EHEC and initially symptomatic with vomiting or diarrhea, shall not work on a restricted basis after being asymptomatic for at least 24 hours. These food employees must remain excluded until they are medically cleared or otherwise meet the criteria for removal from exclusion from a highly susceptible population under subparagraph 2-201.13(D)(1)-(2), 2-201.13(E)(1)-(2), or 2-201.13 (F)(1)-(2).
Food employees diagnosed with hepatitis A virus are always excluded if diagnosed within 14 days of exhibiting any illness symptom, until at least 7 days after the onset of jaundice, or until medically cleared as specified under subparagraphs 2-201.13(B)(1)-(4).
Food employees diagnosed with hepatitis A virus are always excluded if diagnosed within 14 days of exhibiting any illness symptom, until at least 7 days after the onset of jaundice, or until medically cleared as specified under subparagraphs 2-201.13(B)(1)-(3). A food employee with an anicteric infection with the hepatitis A virus has a mild form of hepatitis A without jaundice. Food employees diagnosed with an anicteric infection with the hepatitis A virus are excluded if they are within 14 days of any symptoms. Anicteric, diagnosed food employees shall be removed from exclusion if more than 14 days have passed since they became symptomatic, or if medically cleared. Asymptomatic food employees diagnosed with an active infection with the hepatitis A virus are also excluded until medically cleared.
Food employees diagnosed with typhoid fever (caused by a Salmonella Typhi infection) are always excluded, even without expressing gastrointestinal symptoms, since these symptoms are not typically exhibited with typhoid fever. Outbreaks of foodborne illness involving typhoid fever (Salmonella Typhi) have been traced to asymptomatic food employees who have transmitted the pathogen to food, causing illness. The high virulence combined with the extremely high infectivity of S. Typhi warrant exclusion from the food establishment until the food employee has been cleared by a physician or has completed antibiotic therapy.
Despite lacking specific epidemiological evidence of transmission through food contaminated by food employees infected with E. coli O157:H7 or other EHEC/STEC bacteria are included with the 5 listed pathogens in the Food Code. This is because of the documented ease of transmission from person-to-person in a day care setting and because characteristics of foodborne outbreaks suggest a low infectious dose and the potential for the organism to be transmitted through food contaminated by soiled hands. The severity and consequences of infection, including hemolytic uremic syndrome (HUS), associated with Shiga toxin-producing E. coli warrant the institution of disease interventions.
Asymptomatic shedders are food employees who do not exhibit the symptoms of foodborne illness but who are identified through diagnosis, or laboratory confirmation of their stools to have Norovirus, or any one of the three bacterial pathogens identified in Chapter 2 in their gastrointestinal system.
The risk that food employees who are asymptomatic shedders will transmit a communicable disease varies depending upon the hygienic habits of the worker, the food itself and how it is prepared, the susceptibility of the population served, and the infectivity of the organism. Exclusion in a food establishment that serves a highly susceptible population affords protection to people who are immune-suppressed. Restriction in a food establishment that does not serve a highly susceptible population affords protection for the general population and the immune-suppressed subset of the general population provided there is adequate attention to personal hygiene and avoidance of bare-hand contact with RTE foods.
To minimize the risk in all food establishments of the transmission of foodborne disease by an asymptomatic shedder and based on the factors listed above, all known asymptomatic shedders of the three bacterial pathogens are either restricted or excluded, depending on the population served. Requiring restriction for asymptomatic shedders of all three of the bacterial pathogens results in a uniform criterion and is consistent with APHA-published recommendations in the "Control of Communicable Diseases Manual."
Hands and Arms
2-301.11 Clean Condition.
The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code.
Even seemingly healthy employees may serve as reservoirs for pathogenic microorganisms that are transmissible through food. Staphylococci, for example, can be found on the skin and in the mouth, throat, and nose of many employees. The hands of employees can be contaminated by touching their nose or other body parts.
2-301.12 Cleaning Procedure.
Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to 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 10-15 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.
2-301.13 Special Handwash Procedures.
This section is reserved.
In earlier editions of the Code, FDA's model contained a provision for a Special Procedure in certain situations. Pursuant to a 1996 Conference for Food Protection (CFP) Recommendation, the text of this Code provision is removed and the section is reserved. It is FDA's intent to further research the matter and to submit the findings to the CFP for reconsideration of the matter.
2-301.14 When to Wash.
The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately after the activities listed. The specific examples listed in this Code section are not intended to be all inclusive. Employees must wash their hands after any activity which may result in contamination of the hands.
2-301.15 Where to Wash.
Effective handwashing is essential for minimizing the likelihood of the hands becoming a vehicle of cross contamination. It is important that handwashing be done only at a properly equipped handwashing facility in order to help ensure that food employees effectively clean their hands. Handwashing sinks are to be conveniently located, always accessible for handwashing, maintained so they provide proper water temperatures and pressure, and equipped with suitable hand cleansers, nail brushes, and disposable towels and waste containers, or hand dryers. It is inappropriate to wash hands in a food preparation sink since this may result in avoidable contamination of the sink and the food prepared therein. Service sinks may not be used for food employee handwashing since this practice may introduce additional hand contaminants because these sinks may be used for the disposal of mop water, toxic chemicals, and a variety of other liquid wastes. Such wastes may contain pathogens from cleaning the floors of food preparation areas and toilet rooms and discharges from ill persons.
2-301.16 Hand Antiseptics.
In the 2005 Food Code, the use of the term "hand sanitizer" was replaced by the term "hand antiseptic" to eliminate confusion with the term "sanitizer," a defined term in the Food Code, and to more closely reflect the terminology used in the FDA Tentative Final Monograph for Health-Care Antiseptic Drug Products for OTC Human Use, Federal Register: June 17, 1994.
The term "sanitizer" is typically used to describe control of bacterial contamination of inert objects or articles, or equipment and utensils, and other cleaned food-contact surfaces. The Food Code definition of "sanitizer" requires a minimum microbial reduction of 5 logs, which is equal to a 99.999% reduction. The FDA bases the 5-log reduction on the AOAC International's "Official Methods of Analysis 2003," which requires a minimum 5-log reduction in microorganisms to achieve "sanitization."
Sanitizers used to disinfect food-contact equipment and utensils can easily achieve the 5-log reduction of microorganisms and often far exceed this minimum requirement. However, removing microorganisms from human skin is a totally different process and sterilization of human skin is nearly impossible to achieve without damaging the skin. Many antimicrobial hand agents typically achieve a much smaller reduction in microorganisms than the 5-log reduction required for "sanitization." Therefore, the effect achieved from using antimicrobial hand agents is not consistent with the definition of "sanitization" in the Food Code.
The word "antiseptic" is a Greek term, meaning "against putrefaction", and eventually evolved into a second definition, meaning, "a substance used to destroy pathogenic microorganisms." The term "antiseptic" is often used to describe agents used on skin to prevent infection of the skin.
"Antiseptic" is defined under section 201 (o) of the Federal Food, Drug, and Cosmetic Act (the act) (21 U.S.C. 321 (o)), as: "The representation of a drug, in its labeling, as an antiseptic shall be considered to be a representation of a germicide, except in the case of a drug purporting to be, or represented as, an antiseptic for inhibitory use as a wet dressing, ointment, dusting powder, or such other use as involves prolonged contact with the body."
Section 333.403 of the FDA Tentative Final Monograph for Health-Care Antiseptic Drug Products for OTC Human Use, Federal Register: June 17, 1994, defines a "health-care antiseptic" as an antiseptic-containing drug product applied topically to the skin to help prevent infection or to help prevent cross contamination. An "antiseptic handwash" or "health-care personnel handwash drug product" is defined in Section 333.403 of the Monograph as an antiseptic containing preparation designed for frequent use; it reduces the number of transient microorganisms on intact skin to an initial baseline level after adequate washing, rinsing, and drying; it is a broad spectrum, and persistent antiseptic containing preparation that significantly reduces the number of microorganisms on intact skin.
Replacing the term "hand sanitizer" with the term "hand antiseptic" allows the use of a more scientifically appropriate term that is used to describe reduction of microorganisms on the skin and will improve clarification and regulation of these products.
The provisions of § 2-301.16 are intended to ensure that an antimicrobial product applied to the hands is 1) safe and effective when applied to human skin, and 2) a safe food additive when applied to bare hands that will come into direct contact with food. Because of the need to protect workers and to ensure safe food, hand antiseptics must comply with both the human drug and the food safety provisions of the law. The prohibition against bare hand contact contained in ¶ 3-301.11(B) applies only to an exposed ready-to-eat food.
As a Drug Product
There are two means by which a hand antiseptic is considered to be safe and effective when applied to human skin:
- A hand antiseptic may be approved by FDA under a new drug application based on data showing safety and effectiveness and may be listed in the publication Approved Drug Products with Therapeutic Equivalence Evaluations. This document is maintained by the Food and Drug Administration, Center for Drug Evaluation and Research, Office of Pharmaceutical Science, Office of Generic Drugs. Also known as the "Orange Book," this document provides "product-specific" listings rather than listings by compound and is published annually, with monthly supplements. However, as of the end of 1998, no hand antiseptics are listed in this publication since no new drug applications have been submitted and approved for these products.
- A hand antiseptic active ingredient may be identified by FDA in the monograph for OTC (over-the-counter) Health-Care Antiseptic Drug Products under the antiseptic handwash category. Since hand antiseptic products are intended and labeled for topical antimicrobial use by food employees in the prevention of disease in humans, these products are "drugs" under the Federal Food, Drug, and Cosmetic Act §201(g). As drugs, hand antiseptics and dips must be manufactured by an establishment that is duly registered with the FDA as a drug manufacturer; their manufacturing, processing, packaging, and labeling must be performed in conformance with drug Good Manufacturing Practices (GMP's); and the product must be listed with FDA as a drug product.
Products having the same formulation, labeling, and dosage form as those that existed in the marketplace on or before December 4, 1975, for hand antiseptic use by food handlers, are being evaluated under the Over-the-Counter (OTC) Drug Review by FDA's Center for Drug Evaluation and Research. However, as of May 2005, a final OTC drug monograph for these products has not been finalized. Therefore, FDA has not made a final determination that any of these products are generally recognized as safe and effective (GRAS/E).
GRAS/E antimicrobial ingredients for hand sanitizer use by food handlers will be identified in a future final monograph issued under the OTC Drug Review. Information about whether a specific product is covered by the proposed monograph may be obtained from the tentative final monograph (TFM) for "Health Care Antiseptic Drug Products for OTC Human Use; Proposed Rule." This TFM, which was published in the Federal Register of June 17, 1994 (59 FR 31402), describes the inclusion of hand sanitizers in this Review on page 31440 under Comment 28 of Part II. Information about whether a specific product is included in this proposed monograph may also be available from the manufacturer.
Questions regarding acceptability of a hand antiseptic with respect to OTC compliance may be directed to the Division of New Drugs and Labeling Compliance (HFD-310), Office of Compliance, Center for Drug Evaluation and Research, Food and Drug Administration, 11919 Rockville Pike, Rockville, MD 20852. Specific product label/promotional information and the formulation are required for determining a product's regulatory status.
As a Food Additive
To be subject to regulation under the food additive provisions of the Federal Food, Drug, and Cosmetic Act, the substances in a hand antiseptic must reasonably be expected to become a component of food based upon the product's intended use.
Where the substances in a hand antiseptic are reasonably expected to become a component of food based upon the product's intended use, circumstances under which those substances may be legally used include the following:
- The intended use of a substance may be exempted from regulation as a food additive under 21 CFR 170.39 Threshold of regulation for substances used in food-contact articles. A review by FDA's Center for Food Safety and Applied Nutrition is required in order to determine whether such an exemption can be granted.
- A substance may be regulated for the intended use as a food additive under 21 CFR 174 - Indirect Food Additives - General, and be listed along with conditions of safe use in 21 CFR 178 - Indirect Food Additives: Adjuvants, Production Aids, and Sanitizers.
The intended use of a substance, including substances that contact food such as those in hand antiseptics, may be "generally recognized as safe (GRAS)" within the meaning of the FFDCA. A partial listing of substances with food uses that are generally recognized as safe may be found in CFR Parts 182, 184, and 186. These lists are not exhaustive because the FFDCA allows for independent GRAS determinations.
For the use of a substance to be GRAS within the meaning of the FFDCA, there must be publicly available data that demonstrate that the substance is safe for its intended use. There also must be a basis to conclude that there is a consensus among qualified experts that these publicly available data establish safety. If the use of a substance in food is GRAS, it is not subject to premarket review by FDA. While there is no legal requirement to notify FDA of an independent GRAS determination, a number of firms have chosen to do so with the expectation of receiving a response letter from FDA (see FDA's Inventory of GRAS Notices). Although such a letter does not affirm the independent GRAS determination, it is an opportunity for the firm to receive comment from FDA regarding the materials supporting its determination.
- A substance may be the subject of a Food Contact Substance Notification that became effective in accordance with the FFDCA Section 409 (h). Substances that are the subject of an effective food-contact substance notification are listed, along with conditions of safe use, in the FDA Inventory of Effective Food Contact Substance (FCS) Notifications. This list is available on-line at: Inventory of Effective Food Contact Substance (FCS) Notifications. A food-contact substance that is the subject of an effective notification submitted under FFDCA 409(h) does not include similar or identical substances manufactured or prepared by any person other than the manufacturer identified in that notification.
The Division of Food Contact Substance Notifications does not certify or provide approvals for specific products. However, if the intended use of a substance in contact with food meets the requirements of 21 CFR 170.39 Threshold of regulation for substances used in food-contact articles, FDA may provide a letter to a firm stating that the intended use of this product is exempt from regulation as a food additive. However, the product must be the subject of a new drug application or under FDA's OTC Drug Review to be legally marketed.
Questions regarding the regulatory status of substances in hand antiseptics as food additives may be directed to the Division of Food Contact Substance Notifications, HFS-275, 5100 Paint Branch Parkway, College Park, MD 20740. It may be helpful or necessary to provide label/promotional information when inquiring about a specific substance.
The requirement for fingernails to be trimmed, filed, and maintained is designed to address both the cleanability of areas beneath the fingernails and the possibility that fingernails or pieces of the fingernails may end up in the food due to breakage. Failure to remove fecal material from beneath the fingernails after defecation can be a major source of pathogenic organisms. Ragged fingernails present cleanability concerns and may harbor pathogenic organisms.
Items of jewelry such as rings, bracelets, and watches may collect soil and the construction of the jewelry may hinder routine cleaning. As a result, the jewelry may act as a reservoir of pathogenic organisms transmissible through food.
The term "jewelry" generally refers to the ornaments worn for personal adornment and medical alert bracelets do not fit this definition. However, the wearing of such bracelets carries the same potential for transmitting disease-causing organisms to food. If a food worker wears a medical alert or medical information bracelet, the conflict between this need and the Food Code's requirements can be resolved through reasonable accommodation in accordance with the Americans with Disabilities Act. The person in charge should discuss the Food Code requirement with the employee and together they can work out an acceptable alternative to a bracelet. For example, the medical alert information could be worn in the form of a necklace or anklet to provide the necessary medical information without posing a risk to food. Alternatives to medical alert bracelets are available through a number of different companies (e.g., an internet search using the term "medical alert jewelry" leads to numerous suppliers).
An additional hazard associated with jewelry is the possibility that pieces of the item or the whole item itself may fall into the food being prepared. Hard foreign objects in food may cause medical problems for consumers, such as chipped and/or broken teeth and internal cuts and lesions.
2-304.11 Clean Condition.
Dirty clothing may harbor diseases that are transmissible through food. Food employees who inadvertently touch their dirty clothing may contaminate their hands. This could result in contamination of the food being prepared. Food may also be contaminated through direct contact with dirty clothing. In addition, employees wearing dirty clothes send a negative message to consumers about the level of sanitation in the establishment.
Food Contamination Prevention
2-401.11 Eating, Drinking, or Using Tobacco.
Proper hygienic practices must be followed by food employees in performing assigned duties to ensure the safety of the food, prevent the introduction of foreign objects into the food, and minimize the possibility of transmitting disease through food. Smoking or eating by employees in food preparation areas is prohibited because of the potential that the hands, food, and food-contact surfaces may become contaminated. Unsanitary personal practices such as scratching the head, placing the fingers in or about the mouth or nose, and indiscriminate and uncovered sneezing or coughing may result in food contamination. Poor hygienic practices by employees may also adversely affect consumer confidence in the establishment.
Food preparation areas such as hot grills may have elevated temperatures and the excessive heat in these areas may present a medical risk to the workers as a result of dehydration. Consequently, in these areas food employees are allowed to drink from closed containers that are carefully handled.
2-401.12 Discharges from the Eyes, Nose, and Mouth.
Discharges from the eyes, nose, or mouth through persistent sneezing or coughing by food employees can directly contaminate exposed food, equipment, utensils, linens, and single-service and single-use articles. When these poor hygienic practices cannot be controlled, the employee must be assigned to duties that minimize the potential for contaminating food and surrounding surfaces and objects.
Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair.
2-403.11 Handling Prohibition.
Dogs and other animals, like humans, may harbor pathogens that are transmissible through food. Handling or caring for animals that may be legally present is prohibited because of the risk of contamination of food employee hands and clothing.
, ,  In order to comply with Title I of the Americans with Disabilities Act, an exclusion must also be removed if the employee is entitled to a reasonable accommodation that would eliminate the risk of transmitting the disease. Reasonable accommodation may include reassignment to another position in which the individual would not work around food. The steps an employer must take when an excluded employee requests reasonable accommodation are briefly described in Annex 3, §2-201.11. However, it is not possible to explain all relevant aspects of the ADA within this Annex. When faced with an apparent conflict between ADA and the Food Code's exclusion and restriction requirements, employers should contact the U.S. Equal Employment Opportunity Commission.