Coronavirus outbreak bumps hand hygiene compliance

Hand hygiene is a cornerstone of infection control,1,2 yet compliance remains low, averaging 50% across hospitals nationwide.1 Audit and feedback can improve compliance,3 but audits traditionally occur using direct observation, capturing few events and leading to inaccurate measurements.4 To address this, some institutions have implemented automated monitoring.1,4 

Woman washing her hands at the kitchen sink. There are vegetables out of focus in the background.

To further validate hand hygiene compliance measurements from automated monitoring and estimate the upper bound of compliance achievable with such systems, we describe changes in compliance during the COVID-19 pandemic as measured by the automated system at our institution, one of the largest such deployments nationally.

Hand hygiene compliance rate during the COVID-19 pandemic

JAMA Internal Medicine

Sonya Makhni, MD, MBA1,2Craig A. Umscheid, MD, MS1,2,3Jackie Soo, MPH, ScD3Vera Chu, MS, MLS(ASCP)CM4Allison Bartlett, MD, MS2,4,5Emily Landon, MD1,2,4Rachel Marrs, DNP, RN, CIC4


UK FSA publishes local authority food enforcement info

The information provided by local authorities and compiled by the UK Food Standards Agency, gives a detailed breakdown of enforcement activity across the country.

Monty_Python_reuni_2738729bThe figures for 2014/15 show a continuing trend of increasing compliance levels across the UK.

David Hart, Head of Local Authority Enforcement and Policy Unit, said: ‘I am pleased to see that the figures this year show business hygiene compliance levels are continuing to improve with 93.0% now broadly compliant with hygiene law – this equates to having a food hygiene rating of 3, 4 or 5. The improvement in broad compliance levels was seen in all four countries.’

In Wales the improvement has been more pronounced, increasing over the past three years to 94% from 88% in 2012/13.

For Northern Ireland, the returns covered only the first three quarters of 2014/15. This was agreed, in view of the need for local authorities to focus on preparations for the local government reorganisation, effective from 1 April 2015.

The trend for local authorities to target food hygiene and standards activities at higher risk establishments, rather than carrying out due interventions at lower risk establishments, has continued across the UK. There was a slight reduction in interventions overall – down by 0.8% on the number reported in 2013/14. And there was a further reduction in local authority professional staffing levels – down 3.9% on 2013/14 levels.

The statistics in the report will help the FSA consider  how best to support  its local authority partners.

The FSA monitors local authority performance through Local Authority Enforcement Monitoring System (LAEMS) returns and reports on an annual basis.

Hospital handwashing compliance with video: the video; increases meat safety too

This is a CBS News video of the Arrowsight handwashing video monitoring system that has been used to dramatically increase handwashing compliance rates at North Shore University Hospital in Manhasset, N.Y.

The same system is now being widely used by meat companies in an effort to reduce E. coli and other contamination inside processing plants.

According to a Wall Street Journal article earlier this month, the new technique allows remote auditors to watch whether plant workers follow safety protocols aimed at reducing the spread of deadly bacteria.

JBS SA, the world’s largest beef processor, saw a 60% drop in the level of E. coli found by company inspectors after it installed monitoring cameras, said John Ruby, head of technical services for the company’s beef division. The Brazilian meat processor started with a pilot program after it recalled 380,000 pounds of beef that sickened 23 people in nine states in 2009.

A trial run at its Souderton, Pa., plant showed an immediate improvement in results, so the company placed cameras in all eight of its U.S. plants.

"We are seeing increased interest among meat companies in remote video auditing as part of their food safety and animal welfare programs," said J. Patrick Boyle, president of the American Meat Institute, which represents most beef and pork packing companies. "Those who have implemented these programs have reported very good results."

Cargill Inc., another major U.S. beef producer, uses video cameras to make sure its cattle are treated humanely before they are slaughtered. The Minneapolis-based company is now considering an expansion to monitor for food safety in its pork and turkey operations, according to Mike Siemens, head of the company’s animal welfare division.

Aurora, Ill.-based OSI Group LLC., a meat processor, for several years has used video cameras to monitor employees in three of its five U.S. plants for general food-safety practices. The company, which supplies McDonald’s and other companies with bacon, sausage and chicken, decided in June to expand the monitoring to its other two plants.

After the JBS results, the Agriculture Department—the government agency responsible for overseeing the safety of the U.S. meat supply—in August released voluntary guidelines for video monitoring at meat companies.

In some cases, companies are watching to see if sloppy work is allowing meat contamination. They are also using the cameras to make sure employees aren’t mistakenly sending the expensive cuts into hamburger grinders.

Arrowsight has two facilities—one in Huntsville, Ala., and one in Visakhapatnam, India—employing 50 people to monitor meat-cutting operations. The company was wary about using workers in India, where parts of the country outlaw cattle slaughter, to monitor beef production.

But it hasn’t had problems with that, Mr. Aronson said. Arrowsight routes the most graphic slaughter video to its staff in Huntsville, he said.

Killer cantaloupe facility got big thumbs up from auditor days before outbreak; what retailers relied on those audits? 25 dead, 123 sick means more required than faith-based food safety

 “The contributions of third-party audits to food safety is the same as the contribution of mail-order diploma mills to education. … I have not seen a single company that has had an outbreak or recall that didn’t have a series of audits with really high scores.”
– Mansour Samadpour, president, IEH Laboratories, Seattle

“No one should rely on third-party audits to insure food safety.”
– Will Daniels, food safety, Earthbound Farm

Billions of meals are served safely each day throughout the world. Much of that food is verified as safe by some form of third-party auditor. Yet when outbreaks of foodborne illness happen, the results can be emotionally, physically and financially devastating. And almost all outbreaks involve firms that have received glowing endorsements from food safety auditors.

Food safety auditors are an integral part of the food safety system, and their use will expand in the future, for both domestic and imported foodstuffs. How then to make third-party audits more meaningful, more accurate, and to fully enhance the safety of consumers?

There is a long and spectacular history of food safety failures involving third-party audits (and inspections). Many foodborne illness outbreaks have been linked to farms, processors and retailers that went through some form of certification. The U.S. Government Accountability Office noted in a 2008 report that, while inspectors play an active role in overseeing compliance, the burden for food safety lies primarily with food producers.

In late Oct. 1996, an outbreak of E. coli O157:H7 was traced to juice containing unpasteurized apple cider manufactured by Odwalla in the northwest U.S. Sixty-four people were sickened and a 16-month-old died from E. coli O157:H7. During subsequent grand jury testimony, it was revealed that while Odwalla had written contracts with suppliers to only provide apples picked from trees rather than drops – those that had fallen to the ground and would be more likely to be contaminated with feces, in this case deer feces – the company never bothered to verify if suppliers were actually doing what they said they were doing.

Earlier in 1996, Odwalla had sought to supply the U.S. Army with juice. An Aug. 6, 1996 letter from the Army to Odwalla stated, “we determined that your plant sanitation program does not adequately assure product wholesomeness for military consumers. This lack of assurance prevents approval of your establishment as a source of supply for the Armed Forces at this time.”

Five-year-old Mason Jones was one of 157 people – primarily children – who became ill in an outbreak in South Wales caused by E. coli O157:H7 in September 2005. The outbreak was traced to the consumption of cooked meats provided to schools by John Tudor & Son, a catering butcher business. A packaging machine at the business, used for both raw and cooked meats, was identified as the probable source of contamination – where E. coli O157:H7 was most likely transferred from raw meat to cooked meat that was then distributed to four authorities in South Wales for their school meal programs. The 2005 outbreak was the largest caused by E. coli O157:H7 in Wales and the second largest in the United Kingdom to date; ultimately 31 people were admitted to hospital and, tragically, Mason Jones died.

A public inquiry into the outbreak determined that William Tudor, the proprietor of John Tudor & Son, had a significant disregard for food safety and thus for the health of people who consumed meats produced and distributed by his business. The inquiry heard that there had been serious, and repeated, breaches of federal food safety regulations at the catering butcher business. William Tudor had failed to ensure that critical procedures, such as cleaning and the separation of raw and cooked meats, were carried out effectively. He also falsified certain records that were an important part of food safety practice and deceived Environmental Health Officers (EHOs) on issues such as the use of the packaging machine. The business’s Hazard Analysis Critical Control Point (HACCP) plan was also found to be poorly designed, inaccurate and misleading.

Although foodborne illness may not always be completely preventable, my food safety culture colleague Chris Griffith concluded that the risk of a business causing foodborne illness is, to a large extent, a consequence of its own activities (and its auditors and inspectors).

In Sept. 2006, 199 people were sickened and at least three died from E. coli O157:H7 in bagged spinach produced by Earthbound Farms of California. Samples of river water, wild pig feces, and cattle feces tested positive for the outbreak strain of E. coli O157:H7, and infected feces of nearby grass-fed cattle were found on one of the four fields where the contaminated spinach was grown, under organic production standards, in Salinas Valley. There was no verification that farmers and others in the farm-to-fork food safety system were seriously adapting to the messages about risk and the numbers of sick people, and then translating such information into behavioral changes that enhanced front-line food safety practices, especially in production fields rather than just processing facilities.

On June 28, 2007 the U.S. Food and Drug Administration (FDA) issued a statement warning consumers not to eat Veggie Booty snack food because it had been linked to an outbreak of salmonella.

In July the FDA found Salmonella Wandsworth in the snacks, reconfirming Veggie Booty was the source of the outbreak, after the Minnesota Agricultural Lab had already backed up the epidemiologic evidence with laboratory testing. At the same time, they advised consumers not to eat another product from the same company, Super Veggie Tings Crunchy Corn Sticks, because they might be contaminated as well. Preliminary investigations suggested the seasoning mix might have been the actual source of contamination. The company said the seasoning ingredients came from China, shifting the blame to a country which had failed quality and safety standards for nearly one fifth of their products at the time. A total of 23 states were affected and 69 people became sick.

The plant that made Veggie Booty had received a rating of “excellent” from the American Institute of Baking, raising questions about the efficacy of auditors, which did not extend to ingredient suppliers.

In August 2008, Listeria monocytogenes-contaminated deli meats produced by Maple Leaf Foods, Inc. of Canada caused 57 illnesses and ultimately resulting in 23 deaths. A panel of international food safety experts convened by Maple Leaf Foods, Inc. to investigate the source of the deli meat contamination determined that the most probable contamination source was commercial meat slicers that, despite cleaning according to the manufacturer’s instructions, had meat residue trapped deep inside the slicing mechanisms. The meat residue provided a reservoir and breeding ground for L. monocytogenes. An independent investigative review commissioned by the Canadian federal government provided 57 recommendations to prevent similar outbreaks in the future, reflecting the broad findings of the review: that the focus on food safety was insufficient among senior management at both the company and the various government organizations involved before and during the outbreak; that insufficient planning had been undertaken to be prepared for a potential outbreak; and that those involved lacked a sense of urgency at the outset of the outbreak.

The plant linked to the outbreak received satisfactory marks for complying with federal regulatory requirements. Employees consistently addressed instances of non-compliance when they were identified. The plant’s management maintained all required records, ensured that staff training took place, and ensured the established quality assurance program was followed. At all plants, the company conducted environmental testing that went beyond regulatory requirements. Prior to the outbreak, Maple Leaf Foods, Inc. conducted more than 3,000 environmental tests annually at the implicated plant and tested products monthly. Although no product tests revealed the presence of Listeria spp., a number of environmental samples detected the bacteria in the months before the public was alerted in August to possible contamination. However, the company failed to recognize and identify the underlying cause of a sporadic yet persistent pattern of environmental test results that were positive for Listeria spp. and was not obliged to report the results.

In January 2009, Peanut Corporation of America (PCA) was linked to a growing outbreak across the U.S. caused by Salmonella serotype Typhimurium. On January 9, 2009, the outbreak strain was isolated by the Minnesota Department of Agriculture from an unopened container of King Nut peanut butter – a product manufactured solely by PCA at its facility in Blakely, Georgia. In the ensuing weeks, all peanuts and peanut products processed at Blakely plant since January 1, 2007 were recalled. This included over 3,900 peanut butter and other peanut-containing products from more than 350 companies. PCA supplied peanuts, peanut butter, peanut meal and peanut paste to food processors for use in a wide range of products from cookies, snacks and ice cream to dog treats; to institutions such as hospitals, schools and nursing homes; and directly to consumers through discount retail outlets such as dollar stores. The U.S. Centers for Disease Control and Prevention reported that 691 people were sickened and nine died across 46 U.S. states and in Canada.

Moss and Martin reported in the N.Y. Times that an auditor with the American Institute of baking, based in Manhattan, Kansas, was responsible for evaluating the safety of products produced by PCA. The peanut company knew in advance when the auditors were arriving.

“The overall food safety level of this facility was considered to be: SUPERIOR,” the auditor concluded in his March 27, 2008, report for AIB. A copy of the audit was obtained by The New York Times.

AIB was not alone in missing the trouble at the Peanut Corporation plant in Blakely, Ga. State inspectors also found only minor problems, while a federal team last month uncovered a number of alarming signs, as well as testing records from the company itself that showed salmonella in its products as far back as June 2007.

Nestlé twice inspected PCA plants and chose not to take on PCA as a supplier because it didn’t meet Nestlé’s food-safety standards, according to Nestlé’s audit reports in 2002 and 2006.

“Nestlé audited the Blakely plant in 2002 and rejected it as a supplier. Nestlé’s audit report said the plant needed a "better understanding of the concept of deep cleaning" and failed to adequately separate unroasted raw peanuts from roasted ones. Having them in the same area could allow bacteria on raw nuts to contaminate roasted ones, a risk known as cross-contamination. The plant wasn’t even close to Nestlé’s standards, auditor Richard Hutson said in an interview. Hutson, who now heads quality assurance for several Nestlé divisions, said he shared his concerns with PCA officials at the time, but "they didn’t pursue it" further with Nestlé, he says.”

Kellogg CEO David Mackay testified at a congressional hearing that PCA had been audited by AIB, "the most commonly used auditor in the U.S."

Salmonella in DeCoster eggs in 2010 lead to 2,000 illnesses and the recall of 500 million eggs. They received a superior rating prior to the outbreak from AIB.

That’s a long-winded way of saying, the system of third-party audits can work, but when it fails, it fails spectacularly.

William Neuman of the New York Times reports today the nationwide listeria outbreak that has killed 25 people who ate tainted cantaloupe was probably caused by unsanitary conditions in the packing shed of the Colorado farm where the melons were grown.

Government investigators said that workers had tramped through pools of water where listeria was likely to grow, tracking the deadly bacteria around the shed, which was operated by Jensen Farms, in Granada, Colo. The pathogen was found on a conveyor belt for carrying cantaloupes, a melon drying area and a floor drain, among other places.

This is the part that should give no consumer any confidence:

The farm had passed a food safety audit by an outside contractor just days before the outbreak began. Eric Jensen, a member of the family that runs the farm, said in an e-mail that the auditor had given the packing plant a score of 96 points out of 100.

FDA officials did not criticize the auditor directly. But Michael R. Taylor, deputy commissioner for foods, said the agency intended to establish standards for how auditors should be trained and how audits should be conducted.

The definition of crazy is doing more of the same and expecting a different result: more training will not fix these endemic food safety problems.

Jensen Farms, run by Mr. Jensen and his brother Ryan, had recently acquired a set of used machinery to upgrade the way it washed and dried its cantaloupes. The equipment had been used to clean potatoes and was not intended for use with cantaloupes, officials said. They said the equipment was corroded in places and built in a way that made it difficult to clean and sanitize.

An area used to dry the melons included a cloth cover that could easily have harbored the bacteria, according to a person who discussed the operation with the Jensens.

Officials also said that the cantaloupes had not been adequately cooled before they were placed in refrigerated storage, which could have caused condensation to form on the fruit, creating hospitable conditions for listeria. The bacteria grow well in wet or damp conditions and can also thrive in cold.

Jensen Farms hired an auditor called Primus Labs, based in California, to inspect its facility. Primus gave the job to a subcontractor, Bio Food Safety, which is based in Texas. Jensen and Primus declined to provide a copy of the audit report.
Robert Stovicek, the president of PrimusLabs, said his company had reviewed the audit and found no problems in how it was conducted or in the auditor’s conclusions.

“We thought he did a pretty good job,” Mr. Stovicek said. He said the auditor, James M. DiIorio, has been doing audits for the company since March.

He said that Mr. DiIorio had received two one-week training courses as part of his preparation and had also gone on audits with other auditors.

Asked how Mr. DiIorio could have given high marks to a facility that the F.D.A. described as a breeding ground for listeria, Mr. Stovicek said, “There’s lots of variations as to how people interpret unsanitary conditions.”

Trevor V. Suslow, a professor of food safety at the University of California, Davis, said auditors may give farmers, processors and retailers a false sense of security.

“There needs to be training, certification and auditing of the auditors,” he said.

If third-party auditors and inspectors are part of the food safety solution, then what can be improved? Third-party audits are only one performance indicator but need to be supplemented with microbial testing, second-party audits of suppliers and the in-house capacity to meaningfully assess the results of audits and inspections. Any and all suppliers should be a key focus.

Sprouts ‘safest produce on the grocery shelf’ sick people disagree

Most sprouts are grown in a controlled, indoor environment and, when handled properly, “are the safest produce on the grocery shelf.”

So says Bob Rust, who runs International Specialty Supply, a Cookeville, Tenn.-based supplier of sprout seeds and growing equipment.

Rust told The Packer his company tests every bag of seed before selling it to commercial growers and that most U.S. growers “are well-trained in the production of safe sprouts, utilize some of the most stringent safety procedures in the food industry, and have sophisticated systems in place to minimize the likelihood of contamination.”

Except for those two outbreaks in the U.S. earlier this year; or Canada in 2005; or Germany right now. A complete table of international sprout outbreaks is available at

The Packer responded in an editorial that U.S. sprout growers can do much more than they’re doing to avoid a situation like in Germany, where E. coli-contaminated organic sprouts killed nearly 40 and caused more than 3,000 illnesses.

U.S. sprout grower-shippers contacted in mid-June told us they’re confident their food safety practices have improved significantly in recent years and that thorough testing reduces the chances of contaminated product reaching the food supply.

However, many critics have pointed out dangerous pathogens are more difficult to eliminate in sprouts through current cleaning processes.

The industry has made no clear move to embrace cleaning alternatives, such as irradiation, or form a group similar to the California Leafy Greens Marketing Agreement, which began in the aftermath of the 2006 spinach E. coli outbreak. It is up to each sprout grower to follow food safety guidelines. That’s risky.

The sprout industry needs to do everything it can to ship safe product and prove it to consumers and fellow produce companies.

At this point, they’re not doing that.

Most don’t do the Dracula when sneezing or coughing

Observational research is so much more meaningful – either direct or with video – than self-reported surveys. Of course, everyone says they wash their hands, but they don’t.

Same with blowing the nose or coughing. Health types have been promoting the Dracula-move – expelling your inner germs into the crook of your arm – but when medical students secretly watched hundreds of people cough or sneeze at a train station, a shopping mall and a hospital in New Zealand, most people failed to properly prevent an airborne explosion of infectious germs.

The work was done in the capital city of Wellington over two weeks last August, at the tail end of a worrisome but fairly mild wave of swine flu illnesses. It was a time when the pandemic was international news, and public health campaigns were telling children and adults to be careful about spreading the virus.

The good news is that about three of every four people tried to cover their cough or sneeze, in at least a token attempt to prevent germs from flying through the air.

The bad news is that most people — about two of three — used their hands to do it.

Study author Nick Wilson, an associate professor of public health at the Otago University campus in Wellington, said,

"When you cough into your hands, you cover your hand in virus. Then you touch doorknobs, furniture and other things. And other people touch those and get viruses that way.”

Only 1 in 77 pulled the Dracula move, and about 1 in 30 used a tissue or hankerchief.

The researchers didn’t report numbers on this, but several times they saw people spit on the floor, including at the hospital.

Wilson’s team logged 384 sneezes and coughs.

Vancouver Island doctors – 18 per cent wash their hands

It was awesome when the Canadian women won ice hockey gold at the winter Olympics in Vancouver earlier this year – or for my World Cup obsessed South American students, the what Olympics? – and OK when the Canadian men won gold, but I still say Vancouver is a dump of a town. Always has been.

A new study reported by the Vancouver Sun found that failed handwashing audits for health-care facilities within the Vancouver Island Health Authority produced "disappointing" and "unacceptable" results, according to the head of patient safety.

Doctors were the worst, with a compliance rate of 18 per cent (same percentage seen in other studies).

The health authority improved over last year’s scores of 15 per cent, but, considering the intensive handwashing campaign launched in the face of H1N1 influenza and the increasing number of outbreaks at various facilities, staff members need to do better, according to Dr. Martin Wale, executive medical director of quality and patient safety.


Handwashing: Making it stick

Your Health columnist Kim Painter wants to know in USA Today tomorrow if the spike in handwashing compliance after SARS hit Toronto in 2003 will be replicated with swine flu in 2009 – and will it last?

In summer 2003, researchers descended on airport bathrooms in the USA and Canada and discovered a dirty truth: More than 20% of restroom visitors left without washing their hands.

But there was one big exception: In Toronto, which had just endured a deadly outbreak of severe acute respiratory syndrome (SARS), fewer than 5% of people left dirty-handed. During that outbreak, public health officials had repeatedly urged people to protect themselves by washing their hands.

Doug Powell, a food scientist at Kansas State University, said if changing handwashing behavior was simple, "we wouldn’t have so many people getting sick each year."

The story summarizes handwashing compliance advice for businesses, schools and hospitals as:

•The voice of authority. Just as federal health officials enlisted Obama to endorse handwashing, Dan Dunlop, president of Jennings, a North Carolina marketing company that has designed handwashing promotions for hospitals, has enlisted hospital CEOs and medical chiefs to inspire handwashing in their troops. School principals, PTA presidents and restaurant managers could do likewise, he says.

•The audience. "With younger people, what seems to work is being blunt and gross," Powell says. Powell, who writes at, tells his students that when they eat without washing their hands first, they may be eating feces. (But he uses another word.)

•Social pressure. In one unpublished study, Craig found that petting-zoo visitors who left a barn through a crowded exit washed their hands more often than those who left by a less-crowded door.

•Keeping supplies up. Powell says he hears often about bathrooms in schools, college dormitories and other germ hotspots that lack soap (or paper towel – dp).

Scottish docs told: wash your hands or you’re fired

My high school friend Dave used to say life is a series of hills and valleys: hills and valleys, Boog (that was my nickname, after Baltimore Orioles baseball great, Miller Lite spokesthingy and mesquite barbecue whiz, John “Boog” Powell).

Dave’s descriptor was insightful, to the point and accurate; or just really dull, I’m never quite sure which. I’m reminded of such adjectives when I find myself saying any approach to modifying food safety behavior requires a mixture of carrots and sticks.

I can be amazingly dull.

The National Health Service in Scotland has decided to focus on the sticks bit to get wayward physicians to wash their damn hands: doctors who don’t wash their hands could be fired.

An aide to Health Secretary Nicola Sturgeon said it was “unacceptable” for medical staff to flout hygiene rules, adding,

“Hand hygiene is an important part of our drive to tackle healthcare associated infection. We are now adopting a zero-tolerance approach to non compliance.”