# 10![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# Food Safety

Co-Lead Agencies: Food and Drug Administration\
Food Safety and Inspection Service,\
U.S. Department of Agriculture

### Contents {#contents .Heading-Special}

[Goal Page 10-3](#goal)

[Overview Page 10-3](#overview)

[Issues and Trends Page 10-3](#issues-and-trends)

[Disparities Page 10-6](#disparities)

[Opportunities Page 10-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
10-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
10-9](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
10-10](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
10-16](#related-objectives-from-other-focus-areas)

[Terminology Page 10-16](#terminology)

[References Page 10-18](#references)

##  {#section-1 .unnumbered}

##   {#section-2 .unnumbered}

## Goal

**Reduce foodborne illnesses.**

## Overview

Foodborne illnesses impose a burden on public health and contribute
significantly to the cost of health care.

From 1988 through 1992, foodborne disease outbreaks caused an annual
average of more than 15,000 cases of illness in the United States.[^1]
The actual illness rate may be higher because a count is taken only when
the microorganism that caused the illness is identified by a laboratory
and reported by a physician.

When unreported cases are taken into account, an estimated 76 million
illnesses, 325,000 hospitalizations, and 5,000 deaths each year may be
associated with microorganisms in food.[^2] Hospitalizations due to
foodborne illnesses are estimated to cost over \$3 billion each
year.[^3] The cost of lost productivity is estimated at between \$20
billion and \$40 billion each year.Error: Reference source not found In
addition to acute illness, some microorganisms can cause delayed or
chronic illness. Foodborne chemical contaminants may cause chronic
rather than acute problems, and specific estimates of their impact on
health and the economy are not available.

Since 1996, selected State and local health departments, the Centers for
Disease Control and Prevention (CDC), the Food and Drug Administration
(FDA), and the Food Safety and Inspection Service (FSIS) of the U.S.
Department of Agriculture (USDA) have been cooperating in FoodNet to
produce better national estimates of foodborne disease. The focus is on
organisms that cause the highest number of foodborne illnesses and on
new or emerging foodborne pathogens. Active surveillance, based on
laboratory data, is being conducted at FoodNet sites.

The success of improvements in food production, processing, preparation,
and storage practices can be measured through the reduction in outbreaks
of disease caused by foodborne pathogens. An outbreak occurs when two or
more cases of a similar illness result from eating the same food.Error:
Reference source not found Smaller outbreaks---those with fewer
cases---may be a direct result of improved food preparation practices
and better epidemiologic followup once cases are identified.

### Issues and Trends

Underlying forces may make foodborne illnesses more of a problem in the
years to come. These include emerging pathogens; improper food
preparation, storage, and distribution practices; insufficient training
of retail employees; an increasingly global food supply; and an increase
in the number of people at risk because of aging and compromised
capacity to fight foodborne diseases.[^4]

**Emerging pathogens.** Microorganisms continue to adapt and evolve,
sometimes increasing in their ability to make an individual sick.
Microorganisms previously not recognized as human pathogens or pathogens
unexpectedly found in particular foods have caused outbreaks of illness.
Examples are *Listeria monocytogenes, Escherichia coli* O157:H7, and
*Cyclospora cayetanensis*. Known pathogens also may become resistant to
drugs. For example, some strains of *Salmonella* species now are
resistant to multiple important antimicrobial drugs.

The general trend toward increased resistance by microorganisms to
multiple antimicrobial agents heightens public health concerns about
treatment options and health care costs associated with foodborne
illness. Of particular concern is the potential for transmission of
antimicrobial-resistant pathogens to humans through the food supply. For
these reasons, increased testing is planned to identify and monitor
changes in patterns and trends of antimicrobial resistance in both human
and animal populations.

**Food preparation and storage practices.** Most meals (71 percent) and
snacks (78 percent) are prepared at home.[^5] For these meals, the
food-preparing consumer needs to protect against foodborne illness.
Surveys show that consumers should improve the way they prepare, thaw,
and store food.[^6]**^,^** [^7]

**Training of retail employees.** The retail food industry has a large
employee population with high rates of turnover. Language and literacy
barriers and nonuniform systems for training and certifying workers pose
additional challenges. Improper holding temperatures, inadequate
cooking, poor personal hygiene, contaminated equipment, and foods from
unsafe sources have been associated with foodborne disease outbreaks in
retail food establishments. Retail food employees' use of safe food
preparation and storage practices, along with use of recommended
practices spelled out in the U.S. Public Health Service's *Food Code*,
should reduce outbreaks.

**Global food supply.** An increasing amount of the food eaten in most
countries originates in other countries. Diverse methods of and
standards for growing and processing agricultural products and different
frequencies and types of gastrointestinal infections in food workers in
different regions increase the possibility of food contamination and the
range of pathogens expected.

Protecting the safety of the Nation's food supply involves safeguarding
against both biological and chemical contaminants in food. Chemical
contaminants in food can include pesticides, toxic elements, naturally
occurring toxins (for example, mycotoxins and phytotoxins), antibiotic
residues in animal products, endocrine disruptor compounds, and other
trace substances in food. Many questions remain unanswered about the
chronic effects of exposure to these types of substances. (See Focus
Area 8. Environmental Health.)

The U.S. Environmental Protection Agency (EPA) has set safety standards
(tolerances) to limit the amount of pesticide residues that legally may
remain in or on food or animal feed sold in the United States. Consumers
and others have been concerned about the potential risk to children from
pesticides. The Food Quality Protection Act of 1996 requires EPA to
reassess all existing standards for pesticides by the year 2006. Under
this act, EPA considers the risk from dietary exposures from all food
uses of pesticides and drinking water; nonoccupational exposure, such as
the use of the pesticides for lawn care; and any special sensitivities
for children. FDA monitors domestic and imported foods to ensure
compliance with these pesticide safety standards.[^8] Under the
Pesticide Data Program, USDA's Agricultural Marketing Service measures
how much of certain pesticides remains in or on food.[^9]

Naturally occurring toxins present a different issue. Mycotoxins cannot
be avoided entirely or eliminated from human foods or animal feeds
because the molds that create them occur naturally in grains and other
food commodities. Risk reduction strategies, such as adherence to
specific good manufacturing practices (GMPs), have been developed for
aflatoxins. For other mycotoxins, FDA is using a science-based risk
assessment procedure to help identify appropriate risk reduction
measures.

Because representative national data systems may not be available in the
first half of the decade for tracking progress on mycotoxins in foods,
this subject is not covered in this focus area's objectives. Research on
risk reduction and efforts to collect representative national data on
mycotoxins in foods will be addressed in the coming decade.

**Allergen risk.** Although most foodborne illness results from a
microbial or chemical contaminant in food, a food itself also can cause
severe adverse reactions. In the United States food allergy is an
important problem: 2 to 4 percent of children under age 6
years[^10]**^,^** [^11] and 1 to 2 percent of adults are allergic to
specific foods.[^12] The foods most likely to cause allergic reactions
are milk and milk products, eggs and egg products, peanuts and peanut
products, tree nuts and tree nut products, soybeans and soybean
products, fish and fish products, shellfish and shellfish products,
cereals containing gluten, and seeds. Allergic reactions to natural
rubber latex from food handlers' gloves have been reported.[^13]**^,^**
[^14]

Based on a 3-year study of anaphylaxis cases treated at an emergency
department, an estimated 2,500 individuals per year in the United States
experience food-induced anaphylaxis.[^15]**^,^** [^16] Food allergy is
the most frequent cause of anaphylaxis occurring outside of the hospital
and the most common cause for emergency department visits for
anaphylaxis.[^17] Because potentially allergenic foods are present as
ingredients in a variety of food products, and because even trace
amounts of these allergenic foods can induce anaphylaxis, research,
education, and clear food ingredient labeling information are critical
for managing food allergies.

![](media/image2.wmf){width="4.541666666666667in" height="5.8125in"}The
Food, Drug, and Cosmetic Act requires manufacturers to list all
ingredients of a packaged food, with two exemptions. Spices, flavorings,
and colorings may be declared collectively without each one being
named.[^18] Incidental additives, such as processing aids present in a
food at insignificant levels and not having a technical or functional
effect in the finished food, do not have to be listed individually.[^19]
However, the presence of a substance that may cause an adverse reaction
is considered significant and so it must be listed on the food label.
FDA has advised manufacturers that, because adhering to GMPs is
essential for effective reduction of adverse reactions, precautionary
labeling, such as "may contain (insert name of allergenic ingredient),"
should not be used in lieu of adherence to GMPs.[^20]

### Disparities

More than 30 million people in the United States are likely to be
particularly susceptible to foodborne disease.[^21] Very young, elderly,
and immunocompromised persons experience the most serious foodborne
illnesses. They may become ill from smaller doses of organisms and may
be more likely than other persons to die of foodborne disease. For
example, children under age 1 year have the highest rate of
*Campylobacter* species infections (see figure). Other high-risk
populations include residents in nursing homes or chronic care
facilities; hospitalized, cancer, and organ transplant patients; and
individuals with AIDS, with cirrhosis, on anti-microbial treatment, or
with reduced stomach acid such as due to antacid medications. In cases
of listeriosis and toxoplasmosis, pregnant women and their fetuses or
newborns are at higher risk than other groups.

Representative data on specific U.S. populations, such as racial and
ethnic groups or socioeconomic groups, are not available from FoodNet.
Efforts are under way to improve reporting of this information. A report
from the United Kingdom indicates a relationship between socioeconomic
status and foodborne illness that may apply to the United States. It
found that hospital admissions for gastrointestinal infections increased
with increasing socioeconomic deprivation.[^22]

### Opportunities

The opportunities to reduce the burden of foodborne illness involve risk
reduction and control interventions targeted at various steps from
production to consumption. These strategies include Hazard Analysis and
Critical Control Points programs (required starting in 1997 for seafood
and in 1998 for meat and poultry processing); improved adherence to
GMPs; education of food processors, preparers, and servers at all levels
in the food industry and in the home; and improved investigation of
outbreaks and sporadic cases of foodborne illness.

The Partnership for Food Safety Education was formed in 1997 as a part
of the National Food Safety Initiative. The Partnership---composed of
industry, State, and consumer organizations and government liaisons from
FDA, FSIS, Cooperative State Research, Education, and Extension Service
(CSREES), CDC, and EPA---cooperatively developed the FightBAC!™ Campaign
with messages to reach all consumers. The messages are based on four key
food safety practices:

-   Clean: Wash hands and surfaces often.

-   Separate: Don't cross-contaminate.

-   Cook: Cook to proper temperatures.

-   Chill: Refrigerate promptly.

Increased surveillance, planned as a result of the 1997 initiative and
the improvements to the FoodNet program, will inform the public health
community, veterinary and producer groups, and regulatory agencies of
the extent of the problem of human pathogens that come from the
intestines of animals. These organisms might resist drug therapy when
human illness occurs. Public health experts anticipate an initial
increase in the number of resistant pathogens detected due to improved
surveillance. Over time, as control and educational programs are
enacted, decreases should follow. Wider and more representative testing
will give a better picture of the nature and extent to which
antimicrobial-resistant foodborne pathogens are transmitted from animals
to humans.

## Interim Progress Toward Year 2000 Objectives

Of the four Healthy People 2000 food safety objectives targeted to
reducing foodborne illness, only one has been met---reducing the
incidence of disease caused by four key pathogens (*Salmonella* species,
*Campylobacter* species, *Escherichia coli* O157:H7, and *Listeria
monocytogenes*). Two objectives show solid progress---decreasing the
number of outbreaks of *Salmonella* serotype Enteritidis from 77 to 44
outbreaks per year and State agency adoption (16 States) and review (23
States plus Puerto Rico and the District of Columbia) of the *Food Code*
for retail-level food establishments (1999 *Food Code* data). The
consumer food safety practices objective shows improvement. In fact, the
target for washing cutting boards with soap has been surpassed (79
percent) if all safe practices, such as washing with bleach or using a
different cutting board following use with raw meat or poultry, are
considered.

Note: Data are from the Centers for Disease Control and Prevention,
National\
Center for Health Statistics, *Healthy People 2000 Review, 1998--99,*
and from the\
*Healthy People 2000 Progress Review, Food and Drug Safety,* September
1, 1999*.*

## Healthy People 2010---Summary of Objectives

### Food Safety {#food-safety-1 .Heading-Special-Sub}

**Goal:** Reduce foodborne illnesses.

  ------------ -------------------------------------------------------------
  **Number**   **Objective Short Title**

  10-1         Foodborne infections

  10-2         Outbreaks of foodborne infections

  10-3         Antimicrobial resistance of *Salmonella* species

  10-4         Food allergy deaths

  10-5         Consumer food safety practices

  10-6         Safe food preparation practices in retail establishments

  10-7         Organophosphate pesticide exposure
  ------------ -------------------------------------------------------------

## Healthy People 2010 Objectives

10-1. Reduce infections caused by key foodborne pathogens.

Target and baseline:

+---------+---------------------------+---------------+---------------+
| Ob      | Reduction in Infections   | 1997\         | 2010\         |
| jective | Caused by Microorganisms  | Baseline      | Target        |
+=========+===========================+===============+===============+
|         |                           | ####### Cases |               |
|         |                           |  per 100,000  |               |
+---------+---------------------------+---------------+---------------+
| **1     | *Campylobacter* species   | 24.6          | 12.3          |
| 0-1a.** |                           |               |               |
+---------+---------------------------+---------------+---------------+
| **1     | *Escherichia coli*        | 2.1           | 1.0           |
| 0-1b.** | O157:H7                   |               |               |
+---------+---------------------------+---------------+---------------+
| **1     | *Listeria monocytogenes*  | 0.5           | 0.25          |
| 0-1c.** |                           |               |               |
+---------+---------------------------+---------------+---------------+
| **1     | *Salmonella* species      | 13.7          | 6.8           |
| 0-1d.** |                           |               |               |
+---------+---------------------------+---------------+---------------+
| **1     | *Cyclospora cayetanensis* | Developmental |               |
| 0-1e.** |                           |               |               |
+---------+---------------------------+---------------+---------------+
| **1     | Postdiarrheal hemolytic   | Developmental |               |
| 0-1f.** | uremic syndrome           |               |               |
+---------+---------------------------+---------------+---------------+
| **1     | Congenital *Toxoplasma    | Developmental |               |
| 0-1g.** | gondii*                   |               |               |
+---------+---------------------------+---------------+---------------+

**Target setting method:** 50 percent improvement.

**Data sources:** Foodborne Disease Active Surveillance Network
(FoodNet), CDC, NCID; FDA, CFSAN; FSIS, OPHS; and State agencies.

**Potential data source:** Toxoplasmosis data---National Notifiable
Diseases\
Surveillance System (NNDSS), CDC, NCID.

Note: The table below may continue to the following page.

+---------------------------+---------+---------+---------+---------+
| **Total Population,       | **      | **      | **      | **      |
| 1997**                    | 10-1a.\ | 10-1b.\ | 10-1c.\ | 10-1d.\ |
|                           | *C      | *Esch   | *L      | *Salm   |
|                           | ampylo- | erichia | isteria | onella* |
|                           | bacter\ | coli*   | mon     | Sp      |
|                           | *Sp     | O1      | ocyto-g | ecies** |
|                           | ecies** | 57:H7** | enes*** |         |
+===========================+=========+=========+=========+=========+
|                           | Cases   |         |         |         |
|                           | per     |         |         |         |
|                           | 100,000 |         |         |         |
+---------------------------+---------+---------+---------+---------+
| **TOTAL**                 | 24.6    | 2.1     | 0.5     | 13.7    |
+---------------------------+---------+---------+---------+---------+
| ###### Race and ethnicity |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > American Indian or      | DSU     | DSU     | DSU     | DSU     |
| > Alaska Native           |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Native Hawaiian and     | DSU     | DSU     | DSU     | DSU     |
| > other Pacific Islander  |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Black or African        | DSU     | DSU     | DSU     | DSU     |
| > American                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > White                   | DSU     | DSU     | DSU     | DSU     |
+---------------------------+---------+---------+---------+---------+
|                           |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Hispanic or Latino      | DSU     | DSU     | DSU     | DSU     |
+---------------------------+---------+---------+---------+---------+
| > Not Hispanic or Latino  | DSU     | DSU     | DSU     | DSU     |
+---------------------------+---------+---------+---------+---------+
| > Black or African        | DSU     | DSU     | DSU     | DSU     |
| > American                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > White                   | DSU     | DSU     | DSU     | DSU     |
+---------------------------+---------+---------+---------+---------+
| **Gender**                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Female                  | 21.7    | 2.2     | 0.4     | 13.3    |
+---------------------------+---------+---------+---------+---------+
| > Male                    | 27.5    | 2.0     | 0.5     | 14.0    |
+---------------------------+---------+---------+---------+---------+
| **Family income level**   |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Poor                    | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+
| > Near poor               | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+
| > Middle/high income      | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+
| **Select populations**    |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| Age groups                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| ######## Under 1 year     | 55.5    | 4.6     | 2.3     | 111.4   |
+---------------------------+---------+---------+---------+---------+
| > 1 to 19 years           | 21.9    | 4.9     | 0.1     | 17.5    |
+---------------------------+---------+---------+---------+---------+
| > 20 to 59 years          | 27.2    | 0.9     | 0.3     | 10.7    |
+---------------------------+---------+---------+---------+---------+
| > 60 years and older      | 17.1    | 1.6     | 1.7     | 9.1     |
+---------------------------+---------+---------+---------+---------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Campylobacteriosis and salmonellosis are the most frequently reported
foodborne illnesses in the United States.Error: Reference source not
found The emerging pathogens *E. coli* O157:H7 and *L. monocytogenes*
cause infections that are less often reported but commonly more severe.
*L. monocytogenes* is rare; however, septicemia and meningitis may
result from infection with this organism, and up to 20 percent of
patients may die.Error: Reference source not found Persons with altered
or deficient immune response, such as infants and young children, older
adults, pregnant women and their fetuses, and immunosuppressed persons,
are at highest risk. Listeriosis in pregnant women may lead to
miscarriage, stillbirth, or septicemia and meningitis in newborns.

*Cyclospora cayetanensis,* a parasite, was made a nationally notifiable
disease (States report all cases to CDC) and added to FoodNet in 1998.
Information about this emerging pathogen, such as the proportion of
infections that are foodborne, is needed. Examination for *C.
cayetanensis* is not universal in clinical laboratories; thus, data for
this organism may be less reliable than for the other organisms.

The parasite *Toxoplasma gondii* causes toxoplasmosis and may cause
miscarriage, stillbirth, or fetal abnormality. Although results of
*Toxoplasma gondii* testing are not generally reported by clinicians,
results from national surveys that include blood testing suggest that
toxoplasmosis may be one of the most common infections associated with
food. Blood tests reveal toxoplasmosis infections at a rate of 7.2
percent for children aged 6 to 10 years.[^23] Preliminary data from a
European study showed that a majority of toxoplasmosis cases were
foodborne.[^24] Another study found that food consumption and
preparation practices accounted for five of the top six practices by
pregnant women that were significantly associated with congenital
toxoplasmosis.[^25] The food practices were eating raw or undercooked
minced meat products, eating raw or undercooked mutton, eating raw or
undercooked pork or lamb, eating unwashed raw vegetables, and washing
kitchen knives infrequently after preparation of raw meat and prior to
handling another food item.Error: Reference source not found Changing
the cat litter, although often thought to be the major cause of
toxoplasmosis, ranked fifth in importance of the six practices. As with
other parasitic diseases, diagnostic laboratory testing for
toxoplasmosis often is not available or is done infrequently. Efforts
are under way in the United States to make congenital toxoplasmosis a
nationally notifiable disease, with serological data collection
beginning in 2000.

10-2. Reduce outbreaks of infections caused by key foodborne bacteria.

Target and baseline:

  -------------------------------------------------------------------------------
  Objective        Reduction in Infections        1997\           2010\
                   Caused\                        Baseline        Target
                   by Foodborne Bacteria                          
  ---------------- ------------------------------ --------------- ---------------
                                                  *Number of      
                                                  Outbreaks per   
                                                  Year*           

  **10-2a.**       *Escherichia coli* O157:H7     22              11

  **10**-**2b.**   *Salmonella* serotype          44              22
                   Enteritidis                                    
  -------------------------------------------------------------------------------

**Target setting method:** 50 percent improvement.

**Data source:** Foodborne Disease Outbreak Surveillance System, CDC,
NCID.

Outbreaks of *E. coli* O157:H7 have been associated with undercooked or
raw ground beef, unpasteurized apple juice, and some types of fresh
(raw) produce. The most frequent known cause of outbreaks of
*Salmonella* Enteritidis is the consumption of food that contains
undercooked or raw eggs.

10-3. Prevent an increase in the proportion of isolates of\
*Salmonella* species from humans and from animals at slaughter that are
resistant to antimicrobial drugs.

Target and baseline:

  ---------------------------------------------------------------------------
  Objective    Prevention of Increase in        1997\           2010\
               Proportion of *Salmonella*       Baseline        Target
               Species Resistant to\                            
               Antimicrobial Drugs                              
  ------------ -------------------------------- --------------- -------------
                                                *Percent of     
                                                Isolates*       

               ***Salmonella* from humans that                  
               are resistant to:**                              

  **10-3a.**   Fluoroquinolones                 0               0

  **10-3b.**   Third-generation cephalosporins  0               0

  **10-3c.**   Gentamicin                       3               3

  **10-3d.**   Ampicillin                       18              18

               ***Salmonella* from cattle at                    
               slaughter that are resistant                     
               to:**                                            

  **10-3e.**   Fluoroquinolones                 Developmental   

  **10-3f.**   Third-generation cephalosporins  Developmental   

  **10-3g.**   Gentamicin                       Developmental   

  **10-3h.**   Ampicillin                       Developmental   

               ***Salmonella* from broilers at\                 
               slaughter that are resistant                     
               to:**                                            

  **10-3i.**   Fluoroquinolones                 Developmental   

  **10-3j.**   Third-generation cephalosporins  Developmental   

  **10-3k.**   Gentamicin                       Developmental   

  **10-3l.**   Ampicillin                       Developmental   

               ***Salmonella* from swine at                     
               slaughter that are resistant                     
               to:**                                            

  **10-3m.**   Fluoroquinolones                 Developmental   

  **10-3n.**   Third-generation cephalosporins  Developmental   

  **10-3o.**   Gentamicin                       Developmental   

  **10-3p.**   Ampicillin                       Developmental   
  ---------------------------------------------------------------------------

**Target setting method:** No increase.

**Data sources:** National Antimicrobial Resistance Monitoring System:
Enteric Bacteria--*Salmonella* (NARMS: Enteric Bacteria), CDC, NCID;
FDA, CVM; USDA, FSIS, APHIS, and ARS; Foodborne Disease Active
Surveillance Network\
(FoodNet), CDC, FDA, USDA, FSIS.

10-4. (Developmental) Reduce deaths from anaphylaxis caused by food
allergies.

**Potential data source:** National Vital Statistics System (NVSS), CDC,
NCHS.

10-5. Increase the proportion of consumers who follow key food safety
practices.

**Target:** 79 percent.

**Baseline:** 72 percent of consumers followed key food safety practices
in 1998, based on total population of adults who engaged in the
practice.

**Target setting method:** Better than the best.

**Data source:** Food Safety Survey (FSS), FDA and FSIS, USDA.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adult Population, 1998**                     | **Followed Key Food |
|                                                | Safety\             |
|                                                | Practices**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 72                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 70                  |
+------------------------------------------------+---------------------+
| > White                                        | 73                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 72                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 75                  |
+------------------------------------------------+---------------------+
| > Male                                         | 69                  |
+------------------------------------------------+---------------------+
| **Family income level** (annual)               |                     |
+------------------------------------------------+---------------------+
| > Less than \$10,000                           | DSU                 |
+------------------------------------------------+---------------------+
| > \$10,000 to \$19,999                         | 72                  |
+------------------------------------------------+---------------------+
| > \$20,000 and above                           | 72                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 18 years and older)  |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | DSU                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | 74                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 72                  |
+------------------------------------------------+---------------------+
| ###### Disability status                       |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Children under age 5 years in household        |                     |
+------------------------------------------------+---------------------+
| > No                                           | 72                  |
+------------------------------------------------+---------------------+
| > Yes                                          | 73                  |
+------------------------------------------------+---------------------+
| ###### Age groups                              |                     |
+------------------------------------------------+---------------------+
| > 18 to 59 years                               | 72                  |
+------------------------------------------------+---------------------+
| > 60 years and older                           | 75                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Adjusted to 1993 census proportions on gender, race, and
education.

Note: The table above may have continued from the previous page.

Key food safety practices are based on the four FightBAC!™ Campaign
messages: clean---wash hands and surfaces often; separate---don't
cross-contaminate; cook---cook to proper temperatures; and
chill---refrigerate promptly.

10-6. (Developmental) Improve food employee behaviors and food
preparation practices that directly relate to foodborne illnesses in
retail food establishments.

**Potential data source:** Retail Food Database of Foodborne Illness
Risk Factors, FDA, CFSAN.

Five food safety risk factors related to employee behaviors and
preparation practices have been identified by CDC as contributing to
foodborne illness: improper holding temperatures, inadequate cooking,
contaminated equipment, food from an unsafe source, and poor personal
hygiene. "For each year from 1988 through 1992, the most commonly
reported food preparation practice that contributed to foodborne disease
concerned improper holding temperature; the second concerned poor
personal hygiene of food handlers. Food obtained from an unsafe source
was the least commonly reported factor for all 5 years. In most
outbreaks caused by bacterial pathogens, the food was stored at improper
holding temperatures."Error: Reference source not found

To help control the risk factors, the *Food Code* provides key public
health interventions: use of time-temperature control, prevention of
hand contact with foods as a vehicle of contamination, employee health,
demonstration of knowledge by the manager, and a consumer advisory to
inform consumers of their risk when eating raw or undercooked animal
foods. Proper application and implementation of these interventions are
crucial to combat foodborne disease.

10-7. (Developmental) Reduce human exposure to\
organophosphate pesticides from food.

**Potential data source:** Total Diet Study, FDA, CFSAN.

The Food Quality Protection Act of 1996 mandated that EPA reassess
existing standards for pesticides used on food crops. Organophosphates,
a group of approximately 40 closely related pesticides, have been
designated as first priority in the standards reassessment. These
pesticides are used on fruits and vegetables important in the diet of
children.

## Related Objectives From Other Focus Areas

8\. Environmental Health

8-5. Safe drinking water

8-6. Waterborne disease outbreaks

8-8. Surface water health risks

8-10. Fish contamination

8-24. Exposure to pesticides

8-25. Exposure to heavy metals and other toxic chemicals

8-29. Global burden of disease

8-30. Water quality in the U.S.-Mexico border region

14\. Immunization and Infectious Diseases

14-21. Antimicrobial use in intensive care units

20\. Occupational Safety and Health

20-8. Occupational skin diseases or disorders

23\. Public Health Infrastructure

23-2. Public access to information and surveillance data

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Anaphylaxis:** A severe allergic reaction commonly caused by certain
foods. It occurs within minutes of exposure and may include hives,
itching, skin swelling, blood vessel collapse, shock, and often
life-threatening respiratory distress.[^26]

**Cephalosporins, third generation:** Potent antimicrobial drugs capable
of fighting a wide variety of bacterial infections. *Salmonella* species
infections in certain high-risk and severely ill patients, particularly
children, often are treated with such drugs.

**Emerging pathogen:** An illness-causing microorganism previously
unknown to be a human pathogen, a foodborne pathogen not expected to
occur in particular foods, or a pathogen that has caused a dramatic
increase in new cases of illness.

***Food Code:*** A book of recommendations of the U.S. Public Health
Service that FDA first published in 1993 and revises every 2 years. It
consists of model requirements for safeguarding public health and
ensuring food is unadulterated and honestly presented to the consumer.
FDA offers the *Food Code* for adoption by local, State, Tribal, and
Federal government jurisdictions for administration by the units that
have compliance responsibilities for food service, retail food stores,
or food vending operations.

**Foodborne disease** or **foodborne illness:** Infection or
intoxication caused by microbial or chemical contaminants in foods. Some
foodborne illnesses, such as salmonellosis and staphylococcal food
poisoning, can be caused by a single helping or less of a food that
contains sufficient microorganisms or toxin to cause illness. Other
foodborne illnesses result from eating compounds, such as naturally
occurring aflatoxin, in foods over long periods of time.

**Foodborne disease outbreak:** When two or more cases of a similar
illness result from eating the same food.Error: Reference source not
found

**Food industry:** Food producers (farmers, fishers, ranchers), food
processors, food storers, food warehousers and transporters, and retail
food operators.

**FoodNet:** The Foodborne Diseases Active Surveillance Network, a
collaborative project conducted by CDC, participating States, FSIS, and
FDA that began in 1996. FoodNet produces national estimates of the
burden and sources of specific diseases in the United States through
active surveillance and other studies. California, Connecticut, Georgia,
Maryland, Minnesota, New York, Oregon, and Tennessee, representing a
total population of 28 million people (approximately 10 percent of the
U.S. population), are the eight FoodNet sites.[^27]

**Good manufacturing practices (GMPs):** Criteria, including
regulations, that ensure that food is fit for consumption and is
manufactured under sanitary conditions. These criteria address factors
that affect production of safe food, including disease control,
cleanliness (personal hygiene and dress codes), education, and training.

**Hazard Analysis and Critical Control Points (HACCP):** A science-based
and systematic approach to prevent potential food safety problems by
anticipating how and where biological, chemical, or physical hazards are
most likely to occur and by installing appropriate measures to prevent
them from occurring. The seven principles of HACCP are hazard analysis,
determination of critical control points, specification of critical
limits, monitoring, corrective actions, verification, and documentation
(recordkeeping).

**Hemolytic uremic syndrome (HUS), postdiarrheal:** A serious, sometimes
fatal complication often associated with illness caused by *Escherichia
coli* O157:H7 and other shiga toxin-producing *E. coli*.[^28] HUS occurs
mainly in children under the age of 10 years. Renal failure, hemolytic
anemia, and a severe decrease in the number of blood platelets
characterize HUS.

**Mycotoxins:** Naturally occurring toxins formed by fungi (molds) in
food and in animal feed (for example, aflatoxins, fumonisins,
deoxynivalenol, and patulin).

**Outbreak:** See foodborne disease outbreak above.

**Pathogen:** A microorganism that causes illness.

**Retail food industry:** As covered by the *Food Code*, a level within
the food industry that includes but is not limited to the following
establishments: vending operations, grocery stores, other retail food
outlets, and food service in restaurants and institutions.

## References

[^1]: Centers for Disease Control and Prevention (CDC). Surveillance for
    foodborne-disease outbreaks---United States, 1988--92. *Morbidity
    and Mortality Weekly Report* 45(SS-5):1-55, 1996.

[^2]: Mead, P.S.; Slutsker, L.; Dietz, V.; et al. Food-related illness
    and death in the United States. *Emerging Infectious Diseases*
    5(5):607-625, 1999.

[^3]: Food and Drug Administration (FDA), U.S. Department of Agriculture
    (USDA), and U.S. Environmental Protection Agency (EPA). *Food Safety
    From Farm to Table: A National Food Safety Initiative*. *Report to
    the President, May 1997.* Washington, DC: FDA, USDA, EPA, 1997.

[^4]: U.S. Department of Health and Human Services (HHS). *Healthy
    People 2000 Progress Review, Food and Drug Safety*. Washington, DC:
    HHS, Public Health Service (PHS), Office of Disease Prevention and
    Health Promotion (ODPHP), 1995.

[^5]: Lin, B.H.; Guthrie, J.; and Frazão, E. Away-from-home foods
    increasingly important to quality of American diet. *Agriculture
    Information Bulletin* No. 749, 22, 1999.

[^6]: Altekruse, S.F.; Street, D.A.; Fein, S.B.; et al. Consumer
    knowledge of foodborne microbial hazards and food-handling
    practices. *Journal of Food Protection* 59:287-294, 1996.

[^7]: National Center for Health Statistics (NCHS). *Healthy People 2000
    Review, 1998--99*. Hyattsville, MD: NCHS, 1999, 126-127.

[^8]: FDA. *Pesticide Program Residue Monitoring, 1997*. Washington, DC:
    FDA, 1998.

[^9]: Agricultural Marketing Service. *Pesticide Data Program---Annual
    Summary, Calendar Year 1997*. Washington, DC: USDA, 1997.

[^10]: Kayosaari, M. Food allergy in Finnish children aged 1-6 years.
    *Acta Paediatrica Scandinavica* 71(5):815-819, 1982.

[^11]: Bock, S.A. Prospective appraisal of complaints of adverse
    reactions to foods in children during the first three years of life.
    *Pediatrics* 79(5):683-688, 1987.

[^12]: Sampson, H.A., and Metcalf, D.D. Food allergies. *Journal of the
    American Medical Association* 268(20):2840-2844, 1992.

[^13]: Schwartz, H.J. Latex: A potential hidden "food" allergen in fast
    food restaurants. *Journal of Allergy and Clinical Immunology* 95(1,
    Part 1):139-40, 1995.

[^14]: Tomazic, V.J.; Shampaine, E.L.; Lamanna, A.; et al. Cornstarch
    powder on latex products is an allergen carrier. *Journal of Allergy
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[^15]: Yocum, M.W., and Khan, D.A. Assessment of patients who have
    experienced anaphylaxis: A 3-year survey. *Mayo Clinic Proceedings*
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[^16]: Sampson, H.A. Fatal food-induced anaphylaxis. *Allergy* 53(Suppl.
    46):125-130, 1998.

[^17]: Kemp, S.F.; Lockey, R.F.; Wolf, B.L.; et al. Anaphylaxis.
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[^18]: *Federal Food, Drug, and Cosmetic Act, As Amended* *July 1993.*
    Section 403 (i). Washington, DC: U.S. Government Printing Office
    (GPO), 1993.

[^19]: *Code of Federal Regulations*, Title 21, Part 101, Section 100
    (a)(3). Washington, DC: GPO, 1998.

[^20]: FDA. Notice to Manufacturers: Label Declaration of Allergenic
    Substances in Foods, 1996. Letter from FDA, Center for Food Safety
    and Applied Nutrition, June 10, 1996.

[^21]: Council for Agricultural Science and Technology. *Foodborne
    Pathogens: Risks and Consequences.* Task Force Report No. 122, 1994.

[^22]: Olowokure, B.; Hawker, J.; Weinberg, J.; et al. Deprivation and
    hospital admission for infectious intestinal diseases. *Lancet*
    353(9155):807-808, 1999.

[^23]: NCHS. *National Health and Nutrition Examination Survey III,
    1988--94*. Washington, DC: CDC, National Center for Infectious
    Diseases, unpublished data.

[^24]: CDC. National Workshop on Toxoplasmosis: Preventing Congenital
    Toxoplasmosis. Atlanta, GA, September 9‑10, 1998.

[^25]: Kapperud, G.; Jenum, P.A.; Stray-Pederson, B.; et al. Risk
    factors for *Toxoplasma gondii* infection in pregnancy. Results of a
    prospective case-control study in Norway. *American Journal of
    Epidemiology* 144(4):405-412, 1996.

[^26]: *Dorland's Illustrated Medical Dictionary*. 28th ed.
    Philadelphia, PA: Saunders Co., 1994, 68-69.

[^27]: CDC. *FoodNet 1998 Surveillance Results: Preliminary Report,
    March 1999.* Washington, DC: CDC, 1999.

[^28]: Lindsay, J.A. Chronic sequelae of foodborne disease. *Emerging
    Infectious Diseases* 3(4):443‑452, 1997.