Prevention of food worker transmission of foodborne pathogens: risk assessment and evaluation of effective hygiene intervention strategies

Potential for Glove Risk Amplification via Direct Physical, Chemical, and Microbiological Contamination

This review focuses on the potential direct physical, chemical, and microbiological contamination from disposable gloves when utilized in food environments, inclusive of the risks posed to food products as well as worker safety. Unrecognized problems endemic to glove manufacturing were magnified during the COVID-19 pandemic due to high demand, increased focus on PPE performance, availability, supply chain instability, and labor shortages. Multiple evidence-based reports of contamination, toxicity, illness, deaths, and related regulatory action linked to contaminated gloves in food and healthcare have highlighted problems indicative of systemic glove industry shortcomings. The glove manufacturing process was diagramed with sources and pathways of contamination identified, indicating weak points with documented occurrences detailed. Numerous unsafe ingredients can introduce chemical contaminants, potentially posing risks to food and to glove users. Microbial hazards present significant challenges to overall glove safety as contaminants appear to be introduced via polluted water sources or flawed glove manufacturing processes, resulting in increased risks within food and healthcare environments. Frank and opportunistic pathogens along with food spoilage organisms can be introduced to foods and wearers. When the sources and pathways of glove-borne contamination were explored, it was found that physical failures play a pivotal role in the release of sweat build-up, liquefaction of chemical residues, and incubation of microbial contaminants from hands and gloves. Thus, with glove physical integrity issues, including punctures in new, unused gloves that can develop into significant rips and tears, not only can direct physical food contamination occur but also chemical and microbiological contamination can find their way into food. Enhanced regulatory requirements for Acceptable Quality Limits of food-grade gloves, and the establishment of appropriate bioburden standards would enhance safety in food applications. Based on the information provided, together with a false sense of security associated with glove use, the unconditional belief in glove chemical and microbiological purity may be unfounded.

Microbiological Profiles of Disposable Gloves Used for Handling Ready-to-Eat Foods

Hand hygiene is critical in the food service industry. Bacteria can easily be transferred between different surfaces to food during food preparation. Common hygiene practices include hand washing and usage of disposable gloves. Food handlers are often susceptible to transferring pathogenic bacteria to food, thus proper hand hygiene can limit such transmission. While gloves serve as a barrier between bare hands and food, their misuse, including reuse or lack of change, can potentially result in cross-contamination, compromising on food safety. In Singapore, strict regulations and consumer perceptions have encouraged the use of gloves in food handling. This study assessed the microbiological profile of gloves used by food handlers across fifty randomly chosen food establishments, by swabbing samples from the inner and outer surfaces of gloves. Glove samples were also subjected to a watertight test to detect significant physical damage. The results revealed that gloves with damage exhibited significantly higher mean Standard Plate Counts (SPCs), suggesting the likelihood that damaged gloves promoted the transfer of bacteria. Damaged gloves used to handle certain types of food, like noodles and rice dishes, also had significantly higher mean SPC than those used for beverages and snacks. However, gloves without visible damage showed no significant difference in mean SPC across different food types. The study highlighted that proper glove use can help in preventing bacterial transfer and consequently, maintaining food safety. Regular glove changes, particularly when damaged, are imperative. The findings underscore the importance of proper glove use in conjunction with other hand hygiene practices to uphold food hygiene and safety standards.

Prevalence of intestinal parasites and associated factors among food handlers in food establishments in the Lideta subcity of Addis Ababa, Ethiopia: an institution-based, cross-sectional study

OBJECTIVE

This study was conducted to assess the prevalence of intestinal parasites and the associated factors among food handlers in the Lideta subcity of Addis Ababa, Ethiopia.

DESIGN

An institution-based, cross-sectional study design was used. Stool samples were collected from food handlers and examined using direct wet mount and formalin-ether concentration techniques. Personal and establishment-related information was collected using a pretested questionnaire, with a structured observation. Multivariable binary logistic regression was used to identify factors associated with the prevalence of intestinal parasites on the basis of adjusted OR (AOR) and 95% CI and p values <0.05.

SETTING

Food establishments in the Lideta subcity of Addis Ababa, Ethiopia.

PARTICIPANTS

411 food handlers participated in the study.

OUTCOME MEASURES

The primary outcome was the prevalence of intestinal parasites, defined as the presence of one or more intestinal parasitic species in stool samples.

RESULTS

One or more intestinal parasites were detected in 171 (41.6%; 95% CI 36.6% to 46.4%) stool samples. The most common intestinal parasites were Entamoeba histolytica/dispar (12.7%), Giardia duodenalis (11.2%) and Ascaris lumbricoides (8.3%). The presence of intestinal parasites among food handlers was associated with low monthly income (AOR: 2.83, 95% CI 1.50 to 8.84), untrimmed fingernails (AOR: 4.36, 95% CI 1.98 to 11.90), no food safety training (AOR: 2.51, 95% CI 1.20 to 5.58), low level of education (AOR: 3.13, 95% CI 1.34 to 7.44), poor handwashing practice (AOR: 2.16, 95% CI 1.03 to 4.22) and lack of medical check-up (AOR: 2.31, 95% CI 1.18 to 6.95).

CONCLUSION

The prevalence of intestinal parasites among food handlers in food establishments in the Lideta subcity of Addis Ababa was high. The presence of intestinal parasites was linked to socioeconomic conditions, poor hand hygiene conditions and absence of food safety training. It is crucially important to promote handwashing practices and provide food hygiene and safety training in these settings.

Food Safety Practices and Associated Factors among Food Handlers of Fiche Town, North Shewa Zone, Ethiopia

Background

Foodborne diseases remain a major public health problem globally, but the problem is severe in developing countries like Ethiopia. The objective of this study was to assess food safety practices and associated factors among food handlers of Fiche town.

Methods

A cross-sectional study was conducted among 422 food handlers working in food and drink establishments. The data were collected using a structured questionnaire and observational checklist. Data were entered and coded into SPSS for analysis. Multivariable logistic regression was used to identify the predictor variables associated with the practice of food handlers (p < 0.05).

Result

61.6% of food handlers knew the potential risk of contaminating food with dirty hands, and 70% washed hands with soap before working with food. 52.8% of food handlers covered the hair with restraints. 66.8% of food handlers used outer garments, and the majority of food handlers (71.1%) had a trimmed fingernail. Two hundred thirteen (50.5%) of food handlers had good food handling practices. Medical checkup (AOR = 3.16; 95% CI 1.89, 5.26), sanitary inspection (AOR = 1.76; 95% CI 1.16, 2.69), knowledge (AOR = 2.31; 95% CI 1.53, 3.48), service year (AOR = 3.11; 95% CI 1.53, 6.31), and educational status (AOR = 3.42, 95% CI 1.29, 9.04) were found to be significantly associated with food handling practices.

Conclusion

The food handlers should take various training concerning food hygiene and safety to enhance their knowledge and practice. Regular sanitary inspection of food and drink establishments is recommended.

Effect of a restaurant hygienic grade certificate program on consumer choices

BACKGROUND/OBJECTIVES

The recent coronavirus disease 2019 pandemic has brought to light issues regarding personal and environmental cleanliness. Individuals may have concerns about cleanliness at food service establishments when they consume food prepared at a restaurant. In Korea, a new restaurant hygienic certificate system was implemented in 2017. The effect of this new system has not been evaluated.

SUBJECTS/METHODS

This study investigated consumers' perceptions of these new certificates using the protection motivation theory (PMT). An online survey was conducted to collect data and then exploratory factor analysis, analysis of variance, and multiple regression tests were run.

RESULTS

The results of this study indicate that 3 different certificates had significant differences in threat (P < 0.001) and benefit (P < 0.001) perception. However, experience with a foodborne illness from a restaurant did not effect on the PMT variables. In addition, the 3-tier certificate did not motivate consumers to protect themselves against foodborne illnesses, while previous experiences of foodborne illness (P < 0.05), coping (P < 0.001), and benefits (P < 0.01) affected this protection motivation.

CONCLUSIONS

This study suggests that consumers were not influenced by different certificate levels regarding their motivation to protect themselves from foodborne illnesses. Therefore, an improved plan should be initiated to clarify the meaning of these certificates. The results of this study can help the application and development of a new system for future adaptations.

Evaluation of glove type on survival and transfer of Escherichia coli in model systems and during hand harvesting of lettuce

BACKGROUND

Both reusable and single-use gloves can be employed during hand harvesting of lettuce and leafy greens. The impact of glove type on survival and transfer of Escherichia coli was evaluated using agar or lettuce in a laboratory setting and during simulated lettuce harvesting in the field.

RESULTS

Textured and smooth reusable latex and smooth disposable latex gloves inoculated with E. coli were sequentially touched to 10 or 20 agar plates or 20 lettuce leaves (n = 6; laboratory) or used to sequentially harvest 20 heads of lettuce (n = 6; field). E. coli was recovered by enrichment from significantly fewer leaves (46%; 55 of 120) or heads (26%; 31 of 120) of lettuce when inoculated reusable textured gloves were used compared with disposable gloves (leaves: 98%; 118 of 120, or heads: 74%; 89 of 120). In contrast, when a single head of lettuce was the point source for glove contamination, there was no significant difference in the number of E. coli-positive lettuce heads harvested with reusable textured (71%; 85 of 120) or disposable gloves (75%; 90 of 120). In either field-contamination scenario, at the 20th head of lettuce harvested with a single glove (final sample point), E. coli was recovered from one to five of six lettuce heads across experimental trials.

CONCLUSION

Contamination of a glove from a single point source can lead to subsequent contamination of multiple heads of lettuce during hand harvesting, showing the importance of policies to manage hand hygiene and glove use for harvest crews.

Norovirus transmission mitigation strategies during simulated produce harvest and packing

In the agricultural setting, core global food safety elements, such as hand hygiene and worker furlough, should reduce the risk of norovirus contamination on fresh produce. However, the effect of these practices has not been characterized. Using a quantitative microbial risk model, we evaluated the individual and combined effect of farm-based hand hygiene and worker furlough practices on the maximum risk of norovirus infection from three produce commodities (open leaf lettuce, vine tomatoes, and raspberries). Specifically, we tested two scenarios where a harvester's and packer's norovirus infection status was: 1) assumed positive; or 2) assigned based on community norovirus prevalence estimates. In the first scenario with a norovirus-positive harvester and packer, none of the individual interventions modeled reduced produce contamination to below the norovirus infectious dose. However, combined interventions, particularly high handwashing compliance (100%) and efficacy (6 log10 virus removal achieved using soap and water for 30 s), reduced produce contamination to <1-82 residual virus. Translating produce contamination to maximum consumer infection risk, 100% handwashing with a 5 log10 virus removal was necessary to achieve an infection risk below the threshold of 0.032 infections per consumption event. When community-based norovirus prevalence estimates were applied to the harvester and packer, the single interventions of 100% handwashing with 3 log10 virus removal (average 0.02 infection risk per consumption event) or furlough of the packer (average 0.03 infection risk per consumption event) reduced maximum infection risk to below the 0.032 threshold for all commodities. Bundled interventions (worker furlough, 100% glove compliance, and 100% handwashing with 1-log10 virus reduction) resulted in a maximum risk of 0.02 per consumption event across all commodities. These results advance the evidence-base for global produce safety standards as effective norovirus contamination and risk mitigation strategies.

Designing a Computer-Vision Application: A Case Study for Hand-Hygiene Assessment in an Open-Room Environment

Hand-hygiene is a critical component for safe food handling. In this paper, we apply an iterative engineering process to design a hand-hygiene action detection system to improve food-handling safety. We demonstrate the feasibility of a baseline RGB-only convolutional neural network (CNN) in the restricted case of a single scenario; however, since this baseline system performs poorly across scenarios, we also demonstrate the application of two methods to explore potential reasons for its poor performance. This leads to the development of our hierarchical system that incorporates a variety of modalities (RGB, optical flow, hand masks, and human skeleton joints) for recognizing subsets of hand-hygiene actions. Using hand-washing video recorded from several locations in a commercial kitchen, we demonstrate the effectiveness of our system for detecting hand hygiene actions in untrimmed videos. In addition, we discuss recommendations for designing a computer vision system for a real application.

Hand Contamination among Food Handlers: A Study on the Assessment of Food Handlers in Canteen of Various Hospitals in Solapur City, Maharashtra

Food handlers often act as an important vehicle for the transmission of microorganisms responsible for causing foodborne illness, which pose as a major public health problem of global concern. Poor hygiene while preparation of food is a major source of illness caused by pathogenic microbes. This study was done for a period of 2 months after approval from the Institutional Ethical Committee. The study population included food handlers working in canteens of various hospitals in Solapur. Swabs from hands, nose and fingernail specimens were collected and inoculated on bacteriological culture media and identification was done using standard protocols. Data was collected using a structured questionnaire to evaluate the socio-demographic status and self-hygiene practices followed by the food handlers. Data were analyzed using an appropriate statistical test. All the people involved in food handling including the cook, server and cleaner were included after a written informed consent. The sample size was 45 food handlers. From the 45 food handlers which were included in the study there were 20 cooks (44.44%), 14 servers (31.11%) and 11 cleaners (24.45%) Out of these 45 food handlers 22 (49% ) were males and 23 (51%) were females. Knowledge about basic health education was seen in 73.33% of the subjects, while only 18% were sensitized to hand washing, 22.22% had annual health examination, 35.5% wore finger ornaments. Of 45 food handlers 69% had trimmed fingernails, 73.3% washed their hands regularly. However, no association was found between these factors and hand contamination. This may be because none of the food handlers used soap or hand sanitizer to clean their hands. They used plain water to wash their hands. Food handlers act as an important source in transmission of foodborne illnesses therefore it is necessary to sensitize and create awareness amongst them about the importance of hand hygiene.

Scientific Evidence Supports the Use of Alcohol-Based Hand Sanitizers as an Effective Alternative to Hand Washing in Retail Food and Food Service Settings When Heavy Soiling Is Not Present on Hands

ABSTRACT

Suboptimal food worker health and hygiene has been a common contributing factor in foodborne disease outbreaks for many years. Despite clear U.S. Food and Drug Administration (FDA) Model Food Code recommendations for hand washing and glove use, food worker compliance with hand washing recommendations has remained poor for >20 years. Food workers' compliance with recommended hand washing guidelines is adversely impacted by a number of barriers, including complaints of time pressure, inadequate number and/or location of hand washing sinks and hand washing supplies, lack of food knowledge and training regarding hand washing, the belief that wearing gloves obviates the need for hand washing, insufficient management commitment, and adverse skin effects caused by frequent hand washing. Although many of the issues related to poor hand washing practices in food service facilities are the same as those in health care settings, a new approach to health care hand hygiene was deemed necessary >15 years ago due to persistently low compliance rates among health care personnel. Evidence-based hand hygiene guidelines for health care settings were published by both the Centers for Disease Control and Prevention in 2002 and by the World Health Organization in 2009. Despite similar low hand washing compliance rates among retail food establishment workers, no changes in the Food Code guidelines for hand washing have been made since 2001. In direct contrast to health care settings, where frequent use of alcohol-based hand sanitizers (ABHSs) in lieu of hand washing has improved hand hygiene compliance rates and reduced infections, the Food Code continues to permit the use of ABHSs only after hands have been washed with soap and water. This article provides clear evidence to support modifying the FDA Model Food Code to allow the use of ABHSs as an acceptable alternative to hand washing in situations where heavy soiling is not present. Emphasis on the importance of hand washing when hands are heavily soiled and appropriate use of gloves is still indicated.

HIGHLIGHTS

Investigating Salmonella enterica, Escherichia coli, and Coliforms on Fresh Vegetables Sold in Informal Markets in Cambodia†

ABSTRACT

Vegetables in Cambodia are commonly sold in informal markets lacking food safety standards and controls. Current data on microbial contamination of vegetables in Cambodian informal markets are limited. The purpose of this study was to investigate Salmonella enterica and indicator organisms (Escherichia coli and coliforms) on the surface of fresh vegetables sold in informal markets in Cambodia. Samples of loose-leaf lettuce, tomatoes, and cucumbers were collected from 104 vendors at four informal markets in Battambang and Siem Reap provinces during the rainy and dry seasons. Detection methods for S. enterica were adapted from the U.S. Food and Drug Administration's Bacteriological Analytical Manual. Coliform and E. coli populations were quantified by plating onto E. coli/coliform count plates. S. enterica was most prevalent on lettuce during the dry season (56.5%, 95% confidence interval [CI] [41.0, 70.8]) than during the rainy season (15.4%, 95% CI [7.5, 29.1]), whereas no significant seasonal differences were apparent for tomatoes and cucumbers. Regardless of season, levels of S. enterica were highest on lettuce (5.7 log CFU/g, 95% CI [5.5, 5.9]), relative to cucumbers (4.2 log CFU/g, 95% CI [3.8, 4.6]) and tomatoes (4.3 log CFU/g, 95% CI [4.1, 4.6]). For E. coli, prevalence was higher during the rainy season (34.0%, 95% CI [25.4, 43.8]) than during the dry season (9.1%, 95% CI [4.9, 16.5]), with the highest prevalence estimated on lettuce. Coliform levels on lettuce and tomatoes were greater during the rainy season (6.3 and 5.3 log CFU/g, 95% CI [5.7, 6.8] and [4.7, 5.8], respectively) than during the dry season (5.2 and 3.9 log CFU/g, 95% CI [4.7, 5.7] and [3.4, 4.4], respectively). These results indicate seasonal patterns for microbial prevalence in lettuce and an overall high level of bacterial contamination on raw vegetables sold in Cambodian informal markets.

HIGHLIGHTS

The avenue of fruit wastes to worth for synthesis of silver and gold nanoparticles and their antimicrobial application against foodborne pathogens: A review

The emerging fruit wastes valorization tactic is a strategy for minimizing the dependence on toxic solvents and chemicals commonly used in the preparation of nanoparticles (NPs). Furthermore, the NPs have exhibited promising antimicrobial applications against foodborne pathogens. Hence, a timely review of this topic is in demand to provide a clear insight into the subject. In this article, the synthesis of silver and gold NPs from fruit wastes and their antimicrobial application against foodborne pathogens are reviewed. The extraction method, mechanism of NPs formation and influences of various experimental parameters on the shape and size of the NPs are described. In the second part of the article, antimicrobial activities against foodborne pathogens regarding the nature, optimum composition, surface structure, synergism and morphology of the NPs are reviewed. Furthermore, challenges and future trends related to the synthesis and antimicrobial application of fruit wastes-mediated NPs are discussed.

3D Hierarchical Nanotopography for On-Site Rapid Capture and Sensitive Detection of Infectious Microbial Pathogens

Effective capture and rapid detection of pathogenic bacteria causing pandemic/epidemic diseases is an important task for global surveillance and prevention of human health threats. Here, we present an advanced approach for the on-site capture and detection of pathogenic bacteria through the combination of hierarchical nanostructures and a nuclease-responsive DNA probe. The specially designed hierarchical nanocilia and network structures on the pillar arrays, termed 3D bacterial capturing nanotopographical trap, exhibit excellent mechanical reliability and rapid (<30 s) and irreversible bacterial capturability. Moreover, the nuclease-responsive DNA probe enables the highly sensitive and extremely fast (<1 min) detection of bacteria. The bacterial capturing nanotopographical trap (b-CNT) facilitates the on-site capture and detection of notorious infectious pathogens (Escherichia coli O157:H7, Salmonella enteritidis, Staphylococcus aureus, and Bacillus cereus) from kitchen tools and food samples. Accordingly, the usefulness of the b-CNT is confirmed as a simple, fast, sensitive, portable, and robust on-site capture and detection tool for point-of-care testing.

Assessing Employee Health Policies for Reporting and Excluding Ill Food Employees in Restaurants within the United States

ABSTRACT

Preventing ill food employees from spreading pathogens to food and food contact surfaces remains an important objective of retail food safety policy in the United States. Since 2005, the U.S. Food and Drug Administration (FDA) has recommended food establishments implement employee health policies that include requirements for the exclusion or restriction of ill food employees and reporting, to the person in charge, symptoms or diagnosis of certain diseases transmitted by food. However, the incorporation of this recommendation has not been widely studied. The purpose of this exploratory study was to assess the presence and prevalence of employee health policies at fast-food and full-service restaurants in the United States. More than 50% of fast-food and full-service restaurants were found to have nonexistent employee health policies for each of the five recommended components specified in the FDA Food Code. Results showed 17.41% of fast-food restaurants and 12.88% of full-service restaurants had all five recommended components. Moreover, most restaurants with all five recommended employee health policy components were part of a multiple-unit operation and were found to have more developed food safety management systems than restaurants with none of the recommended components. Further attention and research into the impediments associated with developing and implementing employee health policies in restaurants is warranted.

HIGHLIGHTS

Effect of food safety training on behavior change of food handlers: A case of orange-fleshed sweetpotato purée processing in Kenya

Sweetpotato purée processing is new to Kenya and a rapidly growing value addition activity among informal, small, and medium-sized food enterprises (SMEs) in sub-Saharan Africa (SSA). Inadequate knowledge of food safety and poor hygiene practices by food handlers, low level of compliance with Good Manufacturing Practices (GMPs), and microbial contamination are major food safety challenges in orange-fleshed sweetpotato (OFSP) purée processing in Kenya. The extent of food safety training in enhancing food safety in rural-based SMEs and food processing environments has not been fully investigated. This study aimed at evaluating the impact of food safety training on food safety knowledge and hygiene practices of food handlers and in control of microbial contamination in OFSP purée processing in Kenya. Pre- and post-food safety training assessments were conducted to determine food handler's (N = 14) knowledge and practices on food safety. Food, water, and swab samples (n = 62) from the processing environment were collected before and two months after the training and analyzed for food hygiene indicator microorganisms. The findings indicate a significant (p < 0.05) improvement in overall food safety knowledge and practices of food handlers after the training. Poor knowledge scores were exhibited on aspects of cross-contamination, cleaning, and sanitation but these significantly (p < 0.05) improved after the training. Similarly, microbial counts on food equipment surfaces, installations, personnel hands, and in the final product (OFSP purée) significantly (p < 0.05) declined to acceptable levels after the food safety training. Total counts, yeasts and molds, S. aureus, Enterobacteriaceae, and total coliforms counts in the packaged OFSP purée were 2.6, 1.8, 1.5, 1.9, and 1.2 LOG CFU/g respectively hence suitable for its current application as an ingredient in baked products. The findings from this study indicate food safety training as an appropriate tool for improving food handler's knowledge and hygiene practices as well as enhancing microbial safety and quality of processed foods in SMEs if necessary food safety support resources are provided.

Multi-View Hand-Hygiene Recognition for Food Safety

A majority of foodborne illnesses result from inappropriate food handling practices. One proven practice to reduce pathogens is to perform effective hand-hygiene before all stages of food handling. In this paper, we design a multi-camera system that uses video analytics to recognize hand-hygiene actions, with the goal of improving hand-hygiene effectiveness. Our proposed two-stage system processes untrimmed video from both egocentric and third-person cameras. In the first stage, a low-cost coarse classifier efficiently localizes the hand-hygiene period; in the second stage, more complex refinement classifiers recognize seven specific actions within the hand-hygiene period. We demonstrate that our two-stage system has significantly lower computational requirements without a loss of recognition accuracy. Specifically, the computationally complex refinement classifiers process less than 68% of the untrimmed videos, and we anticipate further computational gains in videos that contain a larger fraction of non-hygiene actions. Our results demonstrate that a carefully designed video action recognition system can play an important role in improving hand hygiene for food safety.

Determinants of Hand Hygiene Practice at Critical Times among Food Handlers in Educational Institutions of the Sagnarigu Municipality of Ghana: A Cross-Sectional Study

INTRODUCTION

Food handlers' hands serve as a vehicle for potential foodborne pathogenic contamination which constitutes a public health risk. In Ghana, there are always constant reports of outbreaks of foodborne diseases in schools. However, determinants of hand hygiene practice among educational institutions food handlers are little known. The study, therefore, aimed to assess the determinants of hand hygiene practice at critical times among educational institutions' food handlers in the Sagnarigu Municipality of Ghana.

METHODS

This was a cross-sectional survey among educational institutions food handlers in the Sagnarigu Municipality. Two hundred and six food handlers were selected through convenience sampling in the educational institutions. At the same time, structured questions that were developed from previous studies were used to assess food handlers' hand hygiene practice at critical times. Data were analyzed using descriptive statistics, bivariate and multivariate logistic regression models. All variables with their respective confidence intervals (95%) and adjusted odds ratios were declared significant at P-values less than .05.

RESULTS

Hand hygiene practice at critical times among the food handlers were relatively good at a rating of 66.0% (95% CI: 59.1, 72.5%). Good hand hygiene practice at critical times was less likely among food handlers with no food safety training (AOR 0.04; 95% CI: 0.00, 0.41) and food handlers who had insufficient knowledge of hand hygiene (AOR 0.06; 95% CI 0.01, 0.25). Good hygiene practice at critical times was 99% lower in food handlers with a negative attitude as compared to food handlers with positive attitudes towards hand hygiene at critical times (AOR 0.01; 95% CI 0.00, 0.07). Only 17.0% of the food handlers demonstrated proper handwashing techniques, whereas a good number (85.4%) of the food handlers did not wash their hands after touching money.

CONCLUSION

Good hand hygiene practice at critical times was relatively good. Food safety training, knowledge of hand hygiene and attitudes towards hand hygiene were independent predictors of hand hygiene practice at critical times. Concerned stakeholders and organizations should focus on WASH interventions that seek to improve educational institutions food handlers' knowledge and attitudes towards hand hygiene, coupled with training on food safety.

Safety Assessment of Foods at Capital Hospital of Pakistan through the Hazard Analysis and Critical Control Point System

ABSTRACT

Food safety is a current challenge that needs to be addressed globally to overcome burden of foodborne diseases. In this study, food samples collected from Pakistan Institute of Medical Sciences, Islamabad, were analyzed for microbial quality. Parameters to measure the presence or absence of Salmonella, Staphylococcus, coliform, fungi, enteropathogenic Escherichia coli, and total viable counts in foods were studied. Enumeration of aerobic mesophilic bacteria and coliform bacteria was carried out to check the quality of water. The results showed that there was microbial contamination in the foods served at hospital under investigation for this study. Most of the contamination existed because of nonhygienic practices by individuals and serving places. Salmonella, fecal coliforms, and fungal cross-contamination was reported. A hazard analysis and critical control point system was implemented to study what areas are at greater risk and are a reason of contamination in the hospital. The study concluded that high prevalence of the microbial contamination was observed in facilities of the Pakistan Institute of Medical Sciences hospital, requiring strict preventive and precautionary measures to be taken to ensure the safety and health of patients and attendants in the hospital.

HIGHLIGHTS

Microbial Quality and Safety of Sushi Prepared with Gloved or Bare Hands: Food Handlers' Impact on Retail Food Hygiene and Safety

Food handlers play an important role in retail food hygiene and safety. This study was conducted to better understand the impact of food handlers on the microbiological quality and safety of sushi and ingredients handled by gloved and bare hands. At retail premises, food handlers were asked to prepare a batch of sushi with raw fish followed by a batch of sushi with cooked ingredients. Food (sushi and ready-to-eat ingredients), hand, and glove samples were collected for analysis of overall microorganisms (standard plate counts) and targeted foodborne bacteria: Staphylococcus aureus, Bacillus cereus, Escherichia coli, Salmonella, and Listeria monocytogenes. Results suggested that cross-contamination was more prevalent at premises where bare hands were used to prepare sushi. When bare hands were used, significantly higher standard plate counts were obtained from samples of cooked rice (2.3 to 4.9 log CFU/g) and sushi (2.8 to 6.9 log CFU/g) and the prevalence of S. aureus in samples was higher on food (21.7%, 28 of 129 samples) and hands (30%, 18 of 60 samples) ( P < 0.05). Glove changing in combination with hand washing minimized cross-contamination during sushi preparation as indicated by the lower prevalence of S. aureus (0%, 0 of 28 samples) and total targeted foodborne bacteria (3.6%, 1 of 28 samples) on the gloves of food handlers who changed gloves and washed their hands compared with those handlers who did not don new gloves. Repeated use of dishcloths could be a cause of cross-contamination, and the prevalence of total targeted foodborne bacteria was significantly higher on hands dried with dishcloths (64.7%, 11 of 17 samples) than on hands dried with paper towels (12.5%, 1 of 8 samples) ( P < 0.05). The prevalences of B. cereus, L. monocytogenes, and Salmonella in the 356 food samples were 5.1% (18 samples), 0.8% (3 samples), and 0%, respectively. Improvements to hand washing, hand drying, and glove changing practices are needed to lower the occurrence of cross-contamination during sushi preparation.

Good Manufacturing Practices and Microbial Contamination Sources in Orange Fleshed Sweet Potato Puree Processing Plant in Kenya

Limited information exists on the status of hygiene and probable sources of microbial contamination in Orange Fleshed Sweet Potato (OFSP) puree processing. The current study is aimed at determining the level of compliance to Good Manufacturing Practices (GMPs), hygiene, and microbial quality in OFSP puree processing plant in Kenya. Intensive observation and interviews using a structured GMPs checklist, environmental sampling, and microbial analysis by standard microbiological methods were used in data collection. The results indicated low level of compliance to GMPs with an overall compliance score of 58%. Microbial counts on food equipment surfaces, installations, and personnel hands and in packaged OFSP puree were above the recommended microbial safety and quality legal limits. Steaming significantly (P < 0.05) reduced microbial load in OFSP cooked roots but the counts significantly (P < 0.05) increased in the puree due to postprocessing contamination. Total counts, yeasts and molds, Enterobacteriaceae, total coliforms, and E. coli and S. aureus counts in OFSP puree were 8.0, 4.0, 6.6, 5.8, 4.8, and 5.9 log₁₀ cfu/g, respectively. In conclusion, equipment surfaces, personnel hands, and processing water were major sources of contamination in OFSP puree processing and handling. Plant hygiene inspection, environmental monitoring, and food safety trainings are recommended to improve hygiene, microbial quality, and safety of OFSP puree.

Quantitative Risk Assessment of Norovirus Transmission in Food Establishments: Evaluating the Impact of Intervention Strategies and Food Employee Behavior on the Risk Associated with Norovirus in Foods

We developed a quantitative risk assessment model using a discrete event framework to quantify and study the risk associated with norovirus transmission to consumers through food contaminated by infected food employees in a retail food setting. This study focused on the impact of ill food workers experiencing symptoms of diarrhea and vomiting and potential control measures for the transmission of norovirus to foods. The model examined the behavior of food employees regarding exclusion from work while ill and after symptom resolution and preventive measures limiting food contamination during preparation. The mean numbers of infected customers estimated for 21 scenarios were compared to the estimate for a baseline scenario representing current practices. Results show that prevention strategies examined could not prevent norovirus transmission to food when a symptomatic employee was present in the food establishment. Compliance with exclusion from work of symptomatic food employees is thus critical, with an estimated range of 75-226% of the baseline mean for full to no compliance, respectively. Results also suggest that efficient handwashing, handwashing frequency associated with gloving compliance, and elimination of contact between hands, faucets, and door handles in restrooms reduced the mean number of infected customers to 58%, 62%, and 75% of the baseline, respectively. This study provides quantitative data to evaluate the relative efficacy of policy and practices at retail to reduce norovirus illnesses and provides new insights into the interactions and interplay of prevention strategies and compliance in reducing transmission of foodborne norovirus.

Microorganisms as an Indicator of Hygiene Status Among Migrant Food Handlers in Peninsular Malaysia

This study used microbial indicators to assess the hygiene status of 383 migrant food handlers from 3 urban cities in Peninsular Malaysia. Microbiological analysis revealed that all the hand swabs tested 99.5% positive for aerobic plate counts (mean [M] ± standard deviation [SD] = 3.57 ± 0.83 log₁₀CFU [colony forming unit]), 20.8% positive for total coliform/ Escherichia coli (M ± SD = 0.30 ± 0.67 log₁₀CFU), and 63.4% positive for Staphylococcus aureus (M ± SD = 1.38 ± 1.26 log₁₀CFU). In addition, aerobic plate counts and Staphylococcus aureus counts exceeded the acceptable standard levels. Bacterial counts were found to be significantly associated with subjects' country of origin ( P = .019) and working responsibilities ( P = .001). Our findings indicate high probability of transmission of pathogenic bacteria from the food handlers' hands to customers during meal preparation and serving. This calls for improvements in personal hygiene and sanitation standards by the relevant health authorities among migrant food handlers.

Contamination of Fresh Produce by Microbial Indicators on Farms and in Packing Facilities: Elucidation of Environmental Routes

To improve food safety on farms, it is critical to quantify the impact of environmental microbial contamination sources on fresh produce. However, studies are hampered by difficulties achieving study designs with powered sample sizes to elucidate relationships between environmental and produce contamination. Our goal was to quantify, in the agricultural production environment, the relationship between microbial contamination on hands, soil, and water and contamination on fresh produce. In 11 farms and packing facilities in northern Mexico, we applied a matched study design: composite samples (n = 636, equivalent to 11,046 units) of produce rinses were matched to water, soil, and worker hand rinses during two growing seasons. Microbial indicators (coliforms, Escherichia coli, Enterococcus spp., and somatic coliphage) were quantified from composite samples. Statistical measures of association and correlations were calculated through Spearman's correlation, linear regression, and logistic regression models. The concentrations of all microbial indicators were positively correlated between produce and hands (ρ range, 0.41 to 0.75; P < 0.01). When E. coli was present on hands, the handled produce was nine times more likely to contain E. coli (P < 0.05). Similarly, when coliphage was present on hands, the handled produce was eight times more likely to contain coliphage (P < 0.05). There were relatively low concentrations of indicators in soil and water samples, and a few sporadic significant associations were observed between contamination of soil and water and contamination of produce. This methodology provides a foundation for future field studies, and results highlight the need for interventions surrounding farmworker hygiene and sanitation to reduce microbial contamination of farmworkers' hands.IMPORTANCE This study of the relationships between microbes on produce and in the farm environment can be used to support the design of targeted interventions to prevent or reduce microbial contamination of fresh produce with associated reductions in foodborne illness.

Assessment of Food Safety Knowledge, Attitude, Self-Reported Practices, and Microbiological Hand Hygiene of Food Handlers

Institutional foodborne illness outbreaks continue to hit the headlines in the country, indicating the failure of food handlers to adhere to safe practices during food preparation. Thus, this study aimed to compare the knowledge, attitude, and self-reported practices (KAP) of food safety assessment and microbiological assessment of food handlers’ hands as an indicator of hygiene practices in food premises. This study involved 85 food handlers working in a university located in Kuala Lumpur, Malaysia. The food safety KAP among food handlers (n = 67) was assessed using a questionnaire; while the hand swabs (n = 85) were tested for the total aerobic count, coliforms, and Escherichia coli, Staphylococcus aureus, Salmonella, Vibrio cholerae and Vibrio parahaemolyticus. The food handlers had moderate levels of food safety knowledge (61.7%) with good attitude (51.9/60) and self-reported practices (53.2/60). It is noteworthy that the good self-reported practices were not reflected in the microbiological assessment of food handlers’ hands, in which 65% of the food handlers examined had a total aerobic count ≥20 CFU/cm² and Salmonella was detected on 48% of the food handlers’ hands. In conclusion, the suggestion of this study was that the food handlers had adequate food safety knowledge, but perceived knowledge failed to be translated into practices at work.

Quantitative farm-to-fork human norovirus exposure assessment of individually quick frozen raspberries and raspberry puree

A quantitative human norovirus (NoV) exposure model describing transmission of NoV during pre-harvest, harvest and further processing of soft red fruits exemplified by raspberries is presented. The outcomes of the model demonstrate the presence of NoV in raspberry puree or individual quick frozen (IQF) raspberry fruits and were generated by Monte Carlo simulations by combining GoldSim® and @Risk® software. Input data were collected from scientific literature, observational studies and assumptions. NoV contamination of soft red fruits is assumed to take place at farms by application of contaminated water for pesticides dilution or by berries' pickers shedding NoV. The model was built simulating that a collection center received berries from ten farms with a total of 245 food handlers picking soft red fruits during a 10-hour day shift. Given 0, 5 and 20 out of 245 berries' pickers were shedding NoV, these conditions were calculated to result in a mean NoV contamination of respectively 0.47, 14.1 and 36.2 NoV particles per kg raspberries in case all raspberries are mixed to one day-batch of 11tons. The NoV contamination of the fruits was mainly driven by the route of NoV shedding food pickers (95.8%) rather than by spraying contaminated pesticide water (4.2%) (baseline scenario with 5 shedding pickers and contaminated pesticide water). Inclusion of appropriate hand washing procedures or hand washing followed by hand disinfection resulted in estimated reductions of the mean NoV levels from 14.1 to 0.16 and 0.17 NoV particles per kg raspberries, respectively, for the baseline scenario with 5 out of 245 food pickers shedding NoV. The use of a mild heat treatment (30s at 75°C) during further processing of berries to purees was noted to reduce mean NoV levels substantially from 14.1 to 0.2 NoV particles per kg raspberry puree. For IQF raspberries, the NoV contamination is heterogeneously distributed and resulted in a mean contamination of 3.1 NoV particles per 250g package containing approximately 115 berries. This farm-to-fork model is a useful tool for evaluating NoV mitigation strategies in the soft red fruit supply chain.

A quantitative exposure model simulating human norovirus transmission during preparation of deli sandwiches

Human noroviruses (HuNoVs) are a major cause of food borne gastroenteritis worldwide. They are often transmitted via infected and shedding food handlers manipulating foods such as deli sandwiches. The presented study aimed to simulate HuNoV transmission during the preparation of deli sandwiches in a sandwich bar. A quantitative exposure model was developed by combining the GoldSim® and @Risk® software packages. Input data were collected from scientific literature and from a two week observational study performed at two sandwich bars. The model included three food handlers working during a three hour shift on a shared working surface where deli sandwiches are prepared. The model consisted of three components. The first component simulated the preparation of the deli sandwiches and contained the HuNoV reservoirs, locations within the model allowing the accumulation of NoV and the working of intervention measures. The second component covered the contamination sources being (1) the initial HuNoV contaminated lettuce used on the sandwiches and (2) HuNoV originating from a shedding food handler. The third component included four possible intervention measures to reduce HuNoV transmission: hand and surface disinfection during preparation of the sandwiches, hand gloving and hand washing after a restroom visit. A single HuNoV shedding food handler could cause mean levels of 43±18, 81±37 and 18±7 HuNoV particles present on the deli sandwiches, hands and working surfaces, respectively. Introduction of contaminated lettuce as the only source of HuNoV resulted in the presence of 6.4±0.8 and 4.3±0.4 HuNoV on the food and hand reservoirs. The inclusion of hand and surface disinfection and hand gloving as a single intervention measure was not effective in the model as only marginal reductions of HuNoV levels were noticeable in the different reservoirs. High compliance of hand washing after a restroom visit did reduce HuNoV presence substantially on all reservoirs. The model showed that good handling practices such as washing hands after a restroom visit, hand gloving, hand disinfection and surface disinfection in deli sandwich bars were an effective way to prevent HuNoV contamination of the prepared foods, but it also demonstrated that further research is needed to ensure a better assessment of the risk of HuNoV transmission during preparation of foods.

A 3-year hygiene and safety monitoring of a meat processing plant which uses raw materials of global origin

A systematic approach in monitoring the hygiene of a meat processing plant using classical microbiological analyses combined with molecular characterization tools may assist in the safety of the final products. This study aimed: (i) to evaluate the total hygiene level and, (ii) to monitor and characterize the occurrence and spread of Salmonella spp. and Listeria monocytogenes in the environment and the final products of a meat industry that processes meat of global origin. In total, 2541 samples from the processing environment, the raw materials, and the final products were collected from a Greek meat industry in the period 2011-2013. All samples were subjected to enumeration of total viable counts (TVC), Escherichia coli (EC) and total coliforms (TCC) and the detection of Salmonella spp., while 709 of these samples were also analyzed for the presence L. monocytogenes. Pathogen isolates were serotyped and further characterized for their antibiotic resistance and subtyped by PFGE. Raw materials were identified as the primary source of contamination, while improper handling might have also favored the proliferation of the initial microbial load. The occurrence of Salmonella spp. and L. monocytogenes reached 5.5% and 26.9%, respectively. Various (apparent) cross-contamination or persistence trends were deduced based on PFGE analysis results. Salmonella isolates showed wide variation in their innate antibiotic resistance, contrary to L. monocytogenes ones, which were found susceptible to all antibiotics except for cefotaxime. The results emphasize the biodiversity of foodborne pathogens in a meat industry and may be used by meat processors to understand the spread of pathogens in the processing environment, as well as to assist the Food Business Operator (FBO) in establishing effective criteria for selection of raw materials and in improving meat safety and quality. This approach can limit the increase of microbial contamination during the processing steps observed in our study as well as the cross contamination of meat products.

Norovirus transmission between hands, gloves, utensils, and fresh produce during simulated food handling

Human noroviruses (HuNoVs), a leading cause of food-borne gastroenteritis worldwide, are easily transferred via ready-to-eat (RTE) foods, often prepared by infected food handlers. In this study, the transmission of HuNoV and murine norovirus (MuNoV) from virus-contaminated hands to latex gloves during gloving, as well as from virus-contaminated donor surfaces to recipient surfaces after simulated preparation of cucumber sandwiches, was inspected. Virus transfer was investigated by swabbing with polyester swabs, followed by nucleic acid extraction from the swabs with a commercial kit and quantitative reverse transcription-PCR. During gloving, transfer of MuNoV dried on the hand was observed 10/12 times. HuNoV, dried on latex gloves, was disseminated to clean pairs of gloves 10/12 times, whereas HuNoV without drying was disseminated 11/12 times. In the sandwich-preparing simulation, both viruses were transferred repeatedly to the first recipient surface (left hand, cucumber, and knife) during the preparation. Both MuNoV and HuNoV were transferred more efficiently from latex gloves to cucumbers (1.2% ± 0.6% and 1.5% ± 1.9%) than vice versa (0.7% ± 0.5% and 0.5% ± 0.4%). We estimated that transfer of at least one infective HuNoV from contaminated hands to the sandwich prepared was likely to occur if the hands of the food handler contained 3 log10 or more HuNoVs before gloving. Virus-contaminated gloves were estimated to transfer HuNoV to the food servings more efficiently than a single contaminated cucumber during handling. Our results indicate that virus-free food ingredients and good hand hygiene are needed to prevent HuNoV contamination of RTE foods.

Norovirus transfer between foods and food contact materials

Human infective noroviruses (NoVs) are a worldwide leading cause of foodborne illness and are frequently spread via infected food handlers preparing and manipulating food products such as deli sandwiches. The objective of the current study was to determine the efficiencies whereby NoV could be transferred between surfaces associated with the preparation of manually prepared foods such as deli sandwiches. Nonfood surfaces included gloves and stainless steel discs, and boiled ham, lettuce, and a sandwich bun were the ingredients of the deli sandwich. Both NoV GII.4 and the murine NoV 1 (MNV-1, a cultivable human NoV surrogate) were included in the presented study. Transfer of NoV GII.4 and MNV-1 between surfaces was performed by pressing an inoculated donor surface against an acceptor surface. To evaluate the effect of subsequent contact, donor surfaces were pressed a second time to an identical acceptor surface. Subsequently, NoV GII.4 and MNV-1 were detected using real-time reverse transcription PCR assays and plaque assays, respectively. Transfer of both viruses from gloves to stainless steel was inefficient, and virus transfer from food products to stainless steel occurred with more variability for NoV GII.4 than for MNV-1. Virus transfer from the stainless steel discs to the gloves was substantially more efficient than from the gloves to the stainless steel. NoV GII.4 and MNV-1 transfer from food products to the gloves occurred with varying efficiencies, although this variation was more evident for NoV GII.4. The MNV-1 inoculum was significantly less efficiently transferred to the acceptor surface at the second contact, which was not the case for NoV GII.4. The obtained transfer efficiency data may provide insights into the transfer of NoV during preparation of foods and can be included in risk assessment models describing the transmission of NoVs in this context.

Evaluation of hygiene practices and microbiological status of ready-to-eat vegetable salads in Spanish school canteens

BACKGROUND

This study was conducted in eight Spanish school canteens during the period 2008-2009. Food handlers' practices, kitchen equipment, hygiene/sanitation conditions and handling practices were evaluated using checklists. In parallel, the microbiological quality and safety of ready-to-eat (RTE) vegetable salads were assessed. In addition, food contact surfaces and environmental air quality of different areas were analysed. The study determined the relationship between the microbiological quality of RTE foods and food handling practices, together with the degree of contamination of working surfaces and environmental contamination of processing and distribution areas.

RESULTS

Some deficiencies were found regarding the use and change of gloves, hand-washing and cleanliness of working surfaces. The microbial levels detected in the foods examined indicated the absence of pathogens in the samples analysed. Surface counts were higher on cutting boards and faucets, showing insufficient cleanliness procedures.

CONCLUSION

This study constitutes a descriptive analysis of the hygiene/sanitation conditions implemented in food service systems in eight Spanish school canteens. The results should help risk managers to better define control measures to be adopted in order to prevent foodborne infections.

Hand hygiene regimens for the reduction of risk in food service environments

Pathogenic strains of Escherichia coli and human norovirus are the main etiologic agents of foodborne illness resulting from inadequate hand hygiene practices by food service workers. This study was conducted to evaluate the antibacterial and antiviral efficacy of various hand hygiene product regimens under different soil conditions representative of those in food service settings and assess the impact of product formulation on this efficacy. On hands contaminated with chicken broth containing E. coli, representing a moderate soil load, a regimen combining an antimicrobial hand washing product with a 70% ethanol advanced formula (EtOH AF) gel achieved a 5.22-log reduction, whereas a nonantimicrobial hand washing product alone achieved a 3.10log reduction. When hands were heavily soiled from handling ground beef containing E. coli, a wash-sanitize regimen with a 0.5% chloroxylenol antimicrobial hand washing product and the 70% EtOH AF gel achieved a 4.60-log reduction, whereas a wash-sanitize regimen with a 62% EtOH foam achieved a 4.11-log reduction. Sanitizing with the 70% EtOH AF gel alone was more effective than hand washing with a nonantimicrobial product for reducing murine norovirus (MNV), a surrogate for human norovirus, with 2.60- and 1.79-log reductions, respectively. When combined with hand washing, the 70% EtOH AF gel produced a 3.19-log reduction against MNV. A regimen using the SaniTwice protocol with the 70% EtOH AF gel produced a 4.04-log reduction against MNV. These data suggest that although the process of hand washing helped to remove pathogens from the hands, use of a wash-sanitize regimen was even more effective for reducing organisms. Use of a high-efficacy sanitizer as part of a wash-sanitize regimen further increased the efficacy of the regimen. The use of a well-formulated alcohol-based hand rub as part of a wash-sanitize regimen should be considered as a means to reduce risk of infection transmission in food service facilities.

Evaluation of food handler practices and microbiological status of ready-to-eat foods in long-term care facilities in the Andalusia region of Spain

Food safety measures in long-term care facilities (LTCFs) are being improved by the introduction of quality control management systems during food production and by the implementation of good manufacturing practices. This study was conducted in LTCFs (geriatric homes) in Andalusia, Spain, during 2008 and 2009 to evaluate sanitary conditions and the microbiological quality and safety of salads and cooked meat products served. A regulation-based checklist was applied to the evaluated centers. Samples of ready-to-eat foods (n = 60) were examined for mesophilic aerobic bacteria (MAB), total coliforms, coagulase-positive staphylococci (CPS), Escherichia coli, Listeria spp., and Salmonella. In parallel, food contact surfaces (working tables, cutting boards, sinks, and faucets) were swabbed and analyzed for MAB and Enterobacteriaceae. The air quality in processing rooms, near sinks, and in canteens also was measured through an active air sampling method for MAB and Staphyloccocus spp. The results obtained revealed some deficiencies regarding handling practices and sanitary conditions tested (i.e., use and change of gloves, hand washing, and cleanliness of work surfaces). The microbial safety of foods examined indicated the absence of pathogens. Average levels of coagulase-positive staphylococci were below 10² CFU/g, and prevalence of E. coli was 6.3% in samples collected. Surface counts were higher on cutting boards and faucets, indicating insufficient cleanliness procedures. This study provides a descriptive analysis of the sanitary conditions of food service systems in LTCF, and this information can help risk managers to better define control measures needed to prevent foodborne infections.

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.