Waterborne Diseases and Wastewater Treatment in Iraq.

Iraq is a desert country with access to large river resources and an extensive aquifer, but these have already been overdrawn for domestic, industry and agriculture use. The diminished flow of the Tigris and Euphrates rivers has allowed seawater intrusion from the Persian Gulf 110 km up as far as Basra, the county's third largest city. In addition, water distribution systems are overloaded and wastewater treatment plants (WWTPs) need upgrading, and fresh water sources polluted by lack of sanitation, agricultural runoff, household and industrial waste, and including the irrigation of vegetables with sewage water, have led to episodes of bacterial, viral and parasitic diseases. Also, there have been increases in many types of cancer since the early 1990s, and based on clinical and epidemiological data, these increases could be attributable to exposure to depleted uranium in the environment arising from conflict in Iraq and particularly during the Iraqi War started 20 years ago. The population affected would like government action to reduce their health concerns, and policies that have been proposed for improving water availability and quality, as well as but have not been followed up sufficiently to tackle these, including increasing the capacity and efficiency of WWTP; promoting the most efficient irrigation techniques for the local growing conditions; reducing the use of chemical fertilizers and pesticides that can decrease the water quality; reducing saline intrusion challenges; building compact desalination units; constructing water storage facilities to address water scarcity challenges; and establishing public education plans for consumers to reduce the water demand during the hot season. Whether the government rises to the task remains to be seen. Also, do those countries that used the DU have a responsibility to remove or otherwise dispose of the fragments that remain?

How has public perception of food safety and health risks changed a year after the pandemic and vaccines roll out?

The recent coronavirus pandemic (COVID-19) has caused unprecedented turmoil and spurred fears that have profoundly changed the public's social and health behaviours, including the perception of food safety risks. One year after the pandemic and the global vaccination campaign, the public perception of food safety and the changes in their hygiene behaviour, health risks concerns, and trust were studied in Jordan, Lebanon, and Tunisia using a cross-sectional online survey. The results of 538 subjects showed a rise in the frequency of hygiene practices, notably in handwashing. Sixty-four percent of the participants were vaccinated, a proportion made up mainly of the Jordanians and Lebanese. For 66% and 64% of the two population groups, respectively, there were no longer trust concerns about COVID-19 health risks following vaccination, whereas the worries about getting COVID-19 persisted for others. Only 47% of participants trusted eating food prepared by vaccinated food handlers. A great majority of the Tunisians (81%) showed varying degrees of concern about COVID-19 transmission from food and the lowest vaccination rate (33%). The current study demonstrated that the impact of vaccination policy positively affects public perception of food-related risks during the pandemic. On the other hand, 33% of the surveyed Jordanians and Tunisians lost trust in the health authorities' management of the pandemic, and 45% of the Lebanese still don't trust them. Communication strategies on health and food safety with the public still represent a challenge for these and probably other countries in the Middle East and North Africa (MENA). Strategies for building and maintaining public trust are crucial to curb persistent fear of food, hence, avoiding potential stigmatization affecting the food economy by promoting health awareness and positive changes in food safety perceptions for safer practices.

The public perception of food and non-food related risks of infection and trust in the risk communication during COVID-19 crisis: A study on selected countries from the Arab region.

The coronavirus pandemic caused a state of panic worldwide. Mixed messages were given about its risk and how to contain it, when trust in authorities and reliable scientific information are essential to reduce unnecessary scares and inappropriate risk perceptions. We know little about public concerns and opinions in health authorities in the Arab world. Thus, an attempt was made to generate such information through a web-based survey. A total of 1074 subjects from Lebanon, Jordan, and Tunisia were recruited to explore their perception of food and non-food risks of infection and the influence of the source of information, trust, and attitudes towards the local authorities' communication of risk. Seventy percent of the respondents were concerned that COVID-19 may be transmitted through food. The perception of risk from touching contaminated surfaces and food packaging and being exposed to infected people during food shopping was even higher. For only less than half of the respondents, the information from local authorities was considered trustworthy and the associated risk communication and response to false rumors were timely, effective, and clear. But the satisfaction level among the Jordanians was remarkably stronger than for the Lebanese and Tunisian respondents. The demographic factors, trust in information, and attitudes towards authorities' performance in risk communication did not influence risk perceptions. Respondents' knowledge was limited based on their chief sources of information, such as social media, local news media broadcasts, and announcements by the World Health Organization. Our conclusion is that unnecessary fear increases among the public when risks that impact heath are unknown. More research in the Arab region is needed to understand the determinants of risk perceptions considering psychological factors on the risk to health. Unfortunately, it is difficult to restrict or contain misleading information from various forms of social media. We recommend that for reducing fear and building confidence with the public for appropriate action during the pandemic, local authorities should enhance the quality and level of details of the information that they share during such crises.

An on-line survey of the behavioral changes in Lebanon, Jordan and Tunisia during the COVID-19 pandemic related to food shopping, food handling, and hygienic practices.

The impact of the novel coronavirus pandemic (COVID-19) has spanned across the various aspects of life globally. Understanding public reactions is vital for effective risk communication and outbreak control and prevention. The Arab world has diverse cultural, economic, and social structures, so public choices and decisions also vary. To investigate the changes in behavior related to food shopping and handling, precautions measures, and hygiene practices of the public during the pandemic, a web-based survey tool was developed and conducted on 1074 subjects in three Arab countries, Lebanon, Jordan, and Tunisia, using a snowball sampling technique. The results showed a significant reduction in RTE consumption during the pandemic, as shown in the 19.2% and 12.2% rise in the proportion of respondents not ordering hot and cold RTE food delivery, respectively. Compared to pre-COVID-19 times, a substantial increase in behaviors related to hygiene and disinfection practices (22.0%-32.2%) was observed with a lesser increase (11.2%) in handwashing practices before food preparation. Moreover, public concerns about contracting COVID-19 from food led to almost doubling the number of Tunisians using cleaning agents for washing fresh fruits and vegetables (e.g., soaps, non-food grade chlorine bleach) besides a 16% and 26.1% increase in use among the Jordanian and Lebanese, respectively. However, a third of the respondents did not follow instructions on labels for the use of chemical products. In conclusion, this study identified culture-specific shortfalls in handwashing and unsafe food handling practices during COVID-19 in the Arab countries and sheds light on the paramount role of coordinated efforts between the local health authorities and the food safety and public health stakeholders in risk communication. To reduce health risks, there need to be rigorous educational campaigns and targeted messages that reach out to the general audience on hand hygiene, the health effects of haphazard use of unsafe chemical compounds on food, and recommendations on following label instructions.

A Review on the Rising Prevalence of International Standards: Threats or Opportunities for the Agri-Food Produce Sector in Developing Countries, with a Focus on Examples from the MENA Region.

Food safety standards are a necessity to protect consumers' health in today's growing global food trade. A number of studies have suggested safety standards can interrupt trade, bringing financial and technical burdens on small as well as large agri-food producers in developing countries. Other examples have shown that economical extension, key intermediaries, and funded initiatives have substantially enhanced the capacities of growers in some countries of the Middle East and North Africa (MENA) region to meet the food safety and quality requirements, and improve their access to international markets. These endeavors often compensate for the weak regulatory framework, but do not offer a sustainable solution. There is a big gap in the food safety level and control systems between countries in the MENA region and those in the developed nations. This certainly has implications for the safety of fresh produce and agricultural practices, which hinders any progress in their international food trade. To overcome the barriers of legal and private standards, food safety should be a national priority for sustainable agricultural development in the MENA countries. Local governments have a primary role in adopting the vision for developing and facilitating the implementation of their national Good Agricultural Practices (GAP) standards that are consistent with the international requirements and adapted to local policies and environment. Together, the public and private sector's support are instrumental to deliver the skills and infrastructure needed for leveraging the safety and quality level of the agri-food chain.

The Impact of Climate Change on Raw and Untreated Wastewater Use for Agriculture, Especially in Arid Regions: A Review.

Climate change is one of the major challenges of our time that pose unprecedented stress to the environment and threats to human health. The global impacts of climate change are vast, spanning from extreme weather events to changes in patterns and distribution of infectious diseases. Lack of rainfall associated with higher temperatures has a direct influence on agricultural production. This is compounded by a growing population forecasted to expand further with increasing needs for food and water. All this has led to the increasing use of wastewater worldwide. In this review, we more specifically discuss the use of untreated wastewater in agriculture in the Middle East and North Africa (MENA) countries, the most arid region in the world. This presents challenges for agriculture with respect to water availability and increasing wastewater use in agri-food chain. This in turn exerts pressures on the safety of food raised from such irrigated crops. Current practices in the MENA region indicate that ineffective water resource management, lack of water quality policies, and slow-paced wastewater management strategies continue to contribute to a decline in water resources and an increased unplanned use of black and graywater in agriculture. Radical actions are needed in the region to improve water and wastewater management to adapt to these impacts. In this regard, the 2006 WHO guidelines for the use of wastewater contain recommendations for the most effective solutions. They provide a step-by-step guide for series of appropriate health protection measures for microbial reduction targets of 6 log units for viral, bacterial, and protozoan pathogens, but these need to be combined with new varieties of crops that are drought and pest resistant. More research into economic local treatment procedures for wastewater in the region is warranted.

Foodborne disease and food control in the Gulf States.

Gulf States in the Middle East have had to change rapidly from subsidence herding, farming and fishing communities to modern states through the exploitation of revenue-generating petroleum products. Fresh water is an even more precious commodity than oil today as this is seen as a rapidly diminishing resource through over use of aquifers with scarce and unpredictable rainfall not replenishing the needs of these countries which increasing rely on reverse-osmosis (RO) desalination of seawater but at a cost in terms of energy. Recycling of waste water and sewage is carried out and used to water urban landscaping and some crops, but there are risks of the presence of pathogens. Much food today is imported to satisfy the requirements of expanding populations, especially foreign workers on temporary visas who make up more than half the residents in many of these Gulf States. Despite limited published data on Gulf States regarding enteric and foodborne diseases and their prevention and control, profiles emerge that can describe the current situation and some future directions. Gastrointestinal diseases, such as typhoid, cholera, and amebic dysentery can be brought into these countries through workers returning from endemic regions, and also through refugees from conflict-torn neighboring countries. However, some diseases are endemic like brucellosis and fatal illnesses from the newly identified Middle East Respiratory Corona Virus (MERS-CoV) associated with camels. In the 1990s, coalition troops stationed during the Gulf War brought in external suppliers and caterers, but using local products like chickens with troops occasionally suffering from infections. The hot climate, particularly in summer, can allow rapid growth of pathogens in foods, especially where refrigeration is not available as in home-prepared lunches by workers and during transportation of foods across traffic-congested cities. One of the biggest concerns for Saudi Arabia is the health oversight of millions during the annual Hajj, and despite much care over restriction of infected pilgrims and care of food, occasional outbreaks have been reported. Government agencies are particularly concerned about restaurant food and try and follow up on complaints of customers but rarely are agents identified; those that have include Salmonella, Bacillus cereus and Staphylococcus aureus. Implicated foods include ethnic products such as Turkish menu items and shawarma. Local culture may play a role in allowing growth of pathogens such as serving women after men at weddings. However, deaths that have been attributed to microbial sources may have been caused by illegal use of pesticides such as aluminum phosphide. Severe penalties have been applied to owners and staff implicated in outbreaks including fines, jail sentences and deportations, which are not typical of Western nations. However, some agencies have initiatives to help educate and train foreign workers in several languages. Foodborne disease surveillance systems are generally not adequate though some countries have initiated modernization of inspection approaches and laboratories. Consumer surveys show that residents have some knowledge of foodborne disease but this could be improved especially for women who do most of the shopping and food preparation in homes. Agencies are increasing directing campaigns for general food safety in their populations, and as long as resources are available, food control is likely to improve over time in Gulf States which is good news for visitors, expatriate workers and citizens alike.

Bacterial contamination in Saeng-go-gi, a ready-to-eat fresh raw beef dish sold in restaurants in South Korea.

This study investigated the bacterial contamination levels in ready-to-eat fresh raw beef, Saeng-go-gi in Korean, sold in restaurants. A total of 462 samples were analyzed by performing an aerobic bacterial plate count, a coliform count, and an Escherichia coli O157:H7 count. Aerobic bacterial plate counts of fresh raw beef obtained from Seoul, Cheonan, Daegu, Gunsan, and Gwangju retail store restaurants were 6.46, 6.89, 6.39, 6.58, and 6.67 log CFU/g, respectively, and coliforms were 4.05, 4.97, 4.76, 3.62, and 3.32 log CFU/g, respectively. Among the 462 assessed samples, suspected E. coli O157:H7 colonies were found in 32, 24, 20, 22, and 16 samples obtained from Seoul, Cheonan, Daegu, Gunsan, and Gwangju, respectively. The identity of these isolated colonies was further assessed by using a latex agglutination kit. The agglutination assay data showed that the isolates were not E. coli O157:H7. The data from this study could be used to design better food handling practices for reducing foodborne illnesses linked to fresh raw beef consumption.

Tracking an Escherichia coli O157:H7-contaminated batch of leafy greens through a pilot-scale fresh-cut processing line.

Cross-contamination of fresh-cut leafy greens with residual Escherichia coli O157:H7-contaminated product during commercial processing was likely a contributing factor in several recent multistate outbreaks. Consequently, radicchio was used as a visual marker to track the spread of the contaminated product to iceberg lettuce in a pilot-scale processing line that included a commercial shredder, step conveyor, flume tank, shaker table, and centrifugal dryer. Uninoculated iceberg lettuce (45 kg) was processed, followed by 9.1 kg of radicchio (dip inoculated to contain a four-strain, green fluorescent protein-labeled nontoxigenic E. coli O157:H7 cocktail at 10(6) CFU/g) and 907 kg (2,000 lb) of uninoculated iceberg lettuce. After collecting the lettuce and radicchio in about 40 bags (∼22.7 kg per bag) along with water and equipment surface samples, all visible shreds of radicchio were retrieved from the bags of shredded product, the equipment, and the floor. E. coli O157:H7 populations were quantified in the lettuce, water, and equipment samples by direct plating with or without prior membrane filtration on Trypticase soy agar containing 0.6% yeast extract and 100 ppm of ampicillin. Based on triplicate experiments, the weight of radicchio in the shredded lettuce averaged 614.9 g (93.6%), 6.9 g (1.3%), 5.0 g (0.8%), and 2.8 g (0.5%) for bags 1 to 10, 11 to 20, 21 to 30, and 31 to 40, respectively, with mean E. coli O157:H7 populations of 1.7, 1.2, 1.1, and 1.1 log CFU/g in radicchio-free lettuce. After processing, more radicchio remained on the conveyor (9.8 g; P < 0.05), compared with the shredder (8.3 g), flume tank (3.5 g), and shaker table (0.1 g), with similar E. coli O157:H7 populations (P > 0.05) recovered from all equipment surfaces after processing. These findings clearly demonstrate both the potential for the continuous spread of contaminated lettuce to multiple batches of product during processing and the need for improved equipment designs that minimize the buildup of residual product during processing.

Transfer of Escherichia coli O157:H7 from equipment surfaces to fresh-cut leafy greens during processing in a model pilot-plant production line with sanitizer-free water.

Escherichia coli O157:H7 contamination of fresh-cut leafy greens has become a public health concern as a result of several large outbreaks. The goal of this study was to generate baseline data for E. coli O157:H7 transfer from product-inoculated equipment surfaces to uninoculated lettuce during pilot-scale processing without a sanitizer. Uninoculated cored heads of iceberg and romaine lettuce (22.7 kg) were processed using a commercial shredder, step conveyor, 3.3-m flume tank with sanitizer-free tap water, shaker table, and centrifugal dryer, followed by 22.7 kg of product that had been dip inoculated to contain ∼10(6), 10(4), or 10(2) CFU/g of a four-strain avirulent, green fluorescent protein-labeled, ampicillin-resistant E. coli O157:H7 cocktail. After draining the flume tank and refilling the holding tank with tap water, 90.8 kg of uninoculated product was similarly processed and collected in ∼5-kg aliquots. After processing, 42 equipment surface samples and 46 iceberg or 36 romaine lettuce samples (25 g each) from the collection baskets were quantitatively examined for E. coli O157:H7 by direct plating or membrane filtration using tryptic soy agar containing 0.6% yeast extract and 100 ppm of ampicillin. Initially, the greatest E. coli O157:H7 transfer was seen from inoculated lettuce to the shredder and conveyor belt, with all equipment surface populations decreasing 90 to 99% after processing 90.8 kg of uncontaminated product. After processing lettuce containing 10(6) or 10(4) E. coli O157:H7 CFU/g followed by uninoculated lettuce, E. coli O157:H7 was quantifiable throughout the entire 90.8 kg of product. At an inoculation level of 10(2) CFU/g, E. coli O157:H7 was consistently detected in the first 21.2 kg of previously uninoculated lettuce at 2 to 3 log CFU/100 g and transferred to 78 kg of product. These baseline E. coli O157:H7 transfer results will help determine the degree of sanitizer efficacy required to better ensure the safety of fresh-cut leafy greens.

Quantitative transfer of Escherichia coli O157:H7 to equipment during small-scale production of fresh-cut leafy greens.

Postharvest contamination and subsequent spread of Escherichia coli O157:H7 can occur during shredding, conveying, fluming, and dewatering of fresh-cut leafy greens. This study quantified E. coli O157:H7 transfer from leafy greens to equipment surfaces during simulated small-scale commercial processing. Three to five batches (22.7 kg) of baby spinach, iceberg lettuce, and romaine lettuce were dip inoculated with a four-strain cocktail of avirulent, green fluorescent protein-labeled, ampicillinresistant E. coli O157:H7 to contain ∼10(6), 10(4), and 10(2) CFU/g, and then were processed after 1 h of draining at ∼23°C or 24 h of storage at 4°C. Lettuce was shredded using an Urschel TransSlicer at two different blade and belt speeds to obtain normal (5 by 5 cm) and more finely shredded (0.5 by 5 cm) lettuce. Thereafter, the lettuce was step conveyed to a flume tank and was washed and then dried using a shaker table and centrifugal dryer. Product (25-g) and water (40-ml) samples were collected at various points during processing. After processing, product contact surfaces (100 cm(2)) on the shredder (n = 14), conveyer (n = 8), flume tank (n = 11), shaker table (n = 9), and centrifugal dryer (n = 8) were sampled using one-ply composite tissues. Sample homogenates diluted in phosphate or neutralizing buffer were plated, with or without prior 0.45- m m membrane filtration, on Trypticase soy agar containing 0.6% yeast extract supplemented with 100 ppm of ampicillin to quantify green fluorescent protein-labeled E. coli O157:H7 under UV light. During leafy green processing, ∼90% of the E. coli O157:H7 inoculum transferred to the wash water. After processing, E. coli O157:H7 populations were highest on the conveyor and shredder (P<0.05), followed by the centrifugal dryer, flume tank, and shaker table, with ∼29% of the remaining product inoculum lost during centrifugal drying. Overall, less (P<0.05) of the inoculum remained on the product after centrifugally drying iceberg lettuce that was held for 1 h (8.13%) as opposed to 24 h (42.18%) before processing, with shred size not affecting the rate of E. coli O157:H7 transfer.

Growth of Listeria monocytogenes in different retail delicatessen meats during simulated home storage.

Delicatessen meats are reported to be the leading vehicle of foodborne listeriosis in the United States. Listeria monocytogenes can reach high numbers in these products during storage, and the growth rate is largely dictated by product formulation and storage temperature. To assess the impact of product age on Listeria growth, five commercial brands each of cured and uncured turkey breast, ham, and roast beef (three lots per brand) were sliced (approximately 25 g per slice) at the beginning of the shelf life, the midpoint, and the last allowable day of sale, surface inoculated with an eight-strain cocktail of L. monocytogenes (approximately 40 CFU/g), and then quantitatively examined for Listeria, lactic acid bacteria, and mesophilic aerobic bacteria during aerobic storage at 4, 7, or 10°C. As expected, L. monocytogenes grew faster in deli meats without rather than with Listeria inhibitors (lactate and/or diacetate) and at the highest storage temperature (10°C). Lag-phase durations for L. monocytogenes in deli meats with and without Listeria inhibitors were 9.21, 6.96, and 5.00 and 6.35, 3.30, and 2.19 days at 4, 7, and 10°C, respectively. Generation times for L. monocytogenes in deli meats with and without Listeria inhibitors were 1.59, 1.53, and 0.85 and 0.94, 0.50, and 0.36 at 4, 7, and 10°C, respectively. Maximum population densities for L. monocytogenes in deli meats with and without Listeria inhibitors were 5.26, 5.92, and 5.97 and 8.47, 8.96 and 9.34 log CFU/g at 4, 7, and 10°C, respectively. Although lactate and diacetate suppressed L. monocytogenes growth, the extent of inhibition differed, ranging from total inhibition in roast beef to only partial inhibition in ham and cured turkey. Listeria growth was also impacted by lot-to-lot variation in the concentrations of Listeria inhibitors, product pH, and background microflora. These data will be useful for developing recommendations for "best consumed by" dating for deli meats using a risk-based approach.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 9. Washing and drying of hands to reduce microbial contamination.

During various daily activities at home and work, hands quickly become contaminated. Some activities increase the risk of finger contamination by pathogens more than others, such as the use of toilet paper to clean up following a diarrheal episode, changing the diaper of a sick infant, blowing a nose, or touching raw food materials. Many foodborne outbreak investigation reports have identified the hands of food workers as the source of pathogens in the implicated food. The most convenient and efficient way of removing pathogens from hands is through hand washing. Important components of hand washing are potable water for rinsing and soaps to loosen microbes from the skin. Hand washing should occur after any activity that soils hands and certainly before preparing, serving, or eating food. Antimicrobial soaps are marginally more effective than plain soaps, but constant use results in a buildup of the antimicrobial compound on the skin. The time taken to wash hands and the degree of friction generated during lathering are more important than water temperature for removing soil and microorganisms. However, excessive washing and scrubbing can cause skin damage and infections. Drying hands with a towel removes pathogens first by friction during rubbing with the drying material and then by wicking away the moisture into that material. Paper rather than cloth towels should be encouraged, although single-use cloth towels are present in the washrooms of higher class hotels and restaurants. Warm air dryers remove moisture and any surface microorganisms loosened by washing from hands by evaporation while the hands are rubbed together vigorously; however, these dryers take too long for efficient use. The newer dryers with high-speed air blades can achieve dryness in 10 to 15 s without hand rubbing.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 7. Barriers to reduce contamination of food by workers.

Contamination of food and individuals by food workers has been identified as an important contributing factor during foodborne illness investigations. Physical and chemical barriers to prevent microbial contamination of food are hurdles that block or reduce the transfer of pathogens to the food surface from the hands of a food worker, from other foods, or from the environment. In food service operations, direct contact of food by hands should be prevented by the use of barriers, especially when gloves are not worn. Although these barriers have been used for decades in food processing and food service operations, their effectiveness is sometimes questioned or their use may be ignored. Physical barriers include properly engineered building walls and doors to minimize the flow of outside particles and pests to food storage and food preparation areas; food shields to prevent aerosol contamination of displayed food by customers and workers; work clothing designated strictly for work (clothing worn outdoors can carry undesirable microorganisms, including pathogens from infected family members, into the work environment); and utensils such as spoons, tongs, and deli papers to prevent direct contact between hands and the food being prepared or served. Money and ready-to-eat foods should be handled as two separate operations, preferably by two workers. Chemical barriers include sanitizing solutions used to remove microorganisms (including pathogens) from objects or materials used during food production and preparation and to launder uniforms, work clothes, and soiled linens. However, laundering as normally practiced may not effectively eliminate viral pathogens.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 8. Gloves as barriers to prevent contamination of food by workers.

The role played by food workers and other individuals in the contamination of food has been identified as an important contributing factor leading to foodborne outbreaks. To prevent direct bare hand contact with food and food surfaces, many jurisdictions have made glove use compulsory for food production and preparation. When properly used, gloves can substantially reduce opportunities for food contamination. However, gloves have limitations and may become a source of contamination if they are punctured or improperly used. Experiments conducted in clinical and dental settings have revealed pinhole leaks in gloves. Although such loss of glove integrity can lead to contamination of foods and surfaces, in the food industry improper use of gloves is more likely than leakage to lead to food contamination and outbreaks. Wearing jewelry (e.g., rings) and artificial nails is discouraged because these items can puncture gloves and allow accumulation of microbial populations under them. Occlusion of the skin during long-term glove use in food operations creates the warm, moist conditions necessary for microbial proliferation and can increase pathogen transfer onto foods through leaks or exposed skin or during glove removal. The most important issue is that glove use can create a false sense of security, resulting in more high-risk behaviors that can lead to cross-contamination when employees are not adequately trained.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps.

Alcohol compounds are increasingly used as a substitute for hand washing in health care environments and some public places because these compounds are easy to use and do not require water or hand drying materials. However, the effectiveness of these compounds depends on how much soil (bioburden) is present on the hands. Workers in health care environments and other public places must wash their hands before using antiseptics and/or wearing gloves. However, alcohol-based antiseptics, also called rubs and sanitizers, can be very effective for rapidly destroying some pathogens by the action of the aqueous alcohol solution without the need for water or drying with towels. Alcohol-based compounds seem to be the most effective treatment against gram-negative bacteria on lightly soiled hands, but antimicrobial soaps are as good or better when hands are more heavily contaminated. Instant sanitizers have no residual effect, unlike some antimicrobial soaps that retain antimicrobial activity after the hygienic action has been completed, e.g., after hand washing. Many alcohol-based hand rubs have antimicrobial agents added to them, but each formulation must be evaluated against the target pathogens in the environment of concern before being considered for use. Wipes also are widely used for quick cleanups of hands, other body parts, and surfaces. These wipes often contain alcohol and/or antimicrobial compounds and are used for personal hygiene where water is limited. However, antiseptics and wipes are not panaceas for every situation and are less effective in the presence of more than a light soil load and against most enteric viruses.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries.

Hand washing with soap is a practice that has long been recognized as a major barrier to the spread of disease in food production, preparation, and service and in health care settings, including hospitals, child care centers, and elder care facilities. Many of these settings present multiple opportunities for spread of pathogens within at-risk populations, and extra vigilance must be applied. Unfortunately, hand hygiene is not always carried out effectively, and both enteric and respiratory diseases are easily spread in these environments. Where water is limited or frequent hand hygiene is required on a daily basis, such as for many patients in hospitals and astronauts in space travel, instant sanitizers or sanitary wipes are thought to be an effective way of preventing contamination and spread of organisms among coworkers and others. Most concerns regarding compliance are associated with the health care field, but the food industry also must be considered. Specific reasons for not washing hands at appropriate times are laziness, time pressure, inadequate facilities and supplies, lack of accountability, and lack of involvement by companies, managers, and workers in supporting proper hand washing. To facilitate improvements in hand hygiene, measurement of compliant and noncompliant actions is necessary before implementing any procedural changes. Training alone is not sufficient for long-lasting improvement. Multiactivity strategies also must include modification of the organization culture to encourage safe hygienic practices, motivation of employees willing to use peer pressure on noncompliant coworkers, a reward and/or penalty system, and an operational design that facilitates regular hand hygiene.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 6. Transmission and survival of pathogens in the food processing and preparation environment.

This article, the sixth in a series reviewing the role of food workers in foodborne outbreaks, describes the source and means of pathogen transfer. The transmission and survival of enteric pathogens in the food processing and preparation environment through human and raw food sources is reviewed, with the main objective of providing information critical to the reduction of illness due to foodborne outbreaks. Pathogens in the food preparation area can originate from infected food workers, raw foods, or other environmental sources. These pathogens can then spread within food preparation or processing facilities through sometimes complex pathways and may infect one or more workers or the consumer of foods processed or prepared by these infected workers. The most frequent means of worker contamination is the fecal-oral route, and study results have indicated that toilet paper may not stop transmission of pathogens to hands. However, contact with raw foods of animal origin, worker aerosols (from sneezes), vomitus, and exposed hand lesions also have been associated with outbreaks. Transfer of pathogens has been documented through contaminated fabrics and carpets, rings, currency, skin surfaces, dust, and aerosols and though person-to-person transmission. Results of experiments on pathogen survival have indicated that transmission depends on the species, the inoculum delivery route, the contact surface type, the duration and temperature of exposure, and the relative humidity. Generally, viruses and encysted parasites are more resistant than enteric bacteria to adverse environmental conditions, but all pathogens can survive long enough for transfer from a contaminated worker to food, food contact surfaces, or fellow workers.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 4. Infective doses and pathogen carriage.

In this article, the fourth in a series reviewing the role of food workers in foodborne outbreaks, background information on the presence of enteric pathogens in the community, the numbers of organisms required to initiate an infection, and the length of carriage are presented. Although workers have been implicated in outbreaks, they were not always aware of their infections, either because they were in the prodromic phase before symptoms began or because they were asymptomatic carriers. Pathogens of fecal, nose or throat, and skin origin are most likely to be transmitted by the hands, highlighting the need for effective hand hygiene and other barriers to pathogen contamination, such as no bare hand contact with ready-to-eat food. The pathogens most likely to be transmitted by food workers are norovirus, hepatitis A virus, Salmonella, Shigella, and Staphylococcus aureus. However, other pathogens have been implicated in worker-associated outbreaks or have the potential to be implicated. In this study, the likelihood of pathogen involvement in foodborne outbreaks where infected workers have been implicated was examined, based on infectious dose, carriage rate in the community, duration of illness, and length of pathogen excretion. Infectious dose estimates are based on volunteer studies (mostly early experiments) or data from outbreaks. Although there is considerable uncertainty associated with these data, some pathogens appear to be able to infect at doses as low as 1 to 100 units, including viruses, parasites, and some bacteria. Lengthy postsymptomatic shedding periods and excretion by asymptomatic individuals of many enteric pathogens is an important issue for the hygienic management of food workers.

Impact of bacterial stress and biofilm-forming ability on transfer of surface-dried Listeria monocytogenes during slicing of delicatessen meats.

Listeria monocytogenes contamination of delicatessen slicer blades can lead to cross-contamination of luncheon meats. A cocktail of 3 strong or 3 weak biofilm-forming strains of L. monocytogenes suspended in turkey slurry was used to inoculate stainless steel delicatessen slicer blades at a level of 6 log CFU/blade. The cocktails were used with or without injury (cold-shocked at 4 degrees C for 2 h, or chlorine-injured at 100 ppm for 1 min). Inoculated blades were held at 22 degrees C/78+/-2% relative humidity for 6 and 24 h, before being used to generate 30 slices from chubs of roast turkey breast or Genoa salami. Slices (25 g) were diluted 1:5 in University of Vermont Medium, homogenized by stomaching and then pour-plated using tryptose phosphate agar supplemented with esculin and ferric ammonium citrate. Greater cumulative transfer to the 30 slices was seen for the strong (3.62 log CFU) as opposed to weak biofilm-forming cocktails (3.12 log CFU) with transfer also significantly greater to turkey (3.61 log CFU) than to salami (3.12 log CFU). Among the three treatments, cold-shock significantly increased subsequent L. monocytogenes transfer (3.69 log CFU) compared to the uninjured control (3.30 log CFU) and chlorine-injury (3.12 log CFU). Significantly greater transfer was also seen for blades used after 6 as opposed to 24 h of incubation. Differences in product composition and survival of L. monocytogenes, as seen via viability staining, are likely reasons for these observed differences in transfer.