Foodborne illness in the United States is a major cause of economic burden, human suffering, and death. Each year, an estimated 6.5 to 33 million people become ill from microorganisms in food, and an estimated 9,000 of these individuals die.
Reducing foodborne illness is one of the priorities listed in the Healthy People 2000 initiative. As part of Healthy People 2000, four objectives, measured by ten indicators, were identified for determining whether efforts by the public and private sectors are successfully reducing foodborne illness. Year 2000 targets were established for each indicator.
The data for three of the four objectives suggest that progress is being made toward achieving the Year 2000 targets.
The incidence of listeriosis and Salmonella enteritis has decreased and significant progress is being made toward the adoption of the new Food Code. On the other hand, the data are not sufficient to fully assess the other indicators.
Progress toward achieving the year 2000 objective for disease caused by Listeria monocytogenes is especially encouraging; however, this success may be difficult to replicate for other pathogens and may even be difficult to maintain for L. monocytogenes. There are several underlying forces that may make foodborne illness more of a problem in the years to come. These underlying forces include:
The status of each of the four objectives is discussed in detail below. The following status report provides a summary of the major strategies being undertaken to achieve the Healthy People 2000 objectives, the major challenges faced by public health officials, the public and private sector partnerships that have been formed, and the new programs that have been initiated.
Ten measurable indicators for four objectives were identified for determining whether the public/private sector efforts were being successful in reducing foodborne illness. Year 2000 quantitative targets were established for each of these indicators.
The first two objectives are to lower the incidence of five foodborne bacterial diseases. The indicators were selected because they are caused by the most important foodborne bacterial pathogens in the United States. As part of objective 12.1, the first two, Salmonella spp. and C. jejuni, are the most prevalent pathogens and Salmonella is the one most well known by the public. The second two, E. coli O157:H7 and L. monocytogenes, while considerably less prevalent, are the two foodborne pathogens that cause the most severe illnesses and have significant impact on the very young, the elderly, and those with chronic disease or impaired immune systems. The fifth indicator, the only indicator for objective 12.2, S. enteritidis, was selected because outbreaks of S. enteritidis infection increased dramatically over the decade of the 1980's, and the organism was of increasing concern to public health officials.
Since the overall strategy for reducing foodborne illness is to place a heavy emphasis on education about proper food storage and preparation practices, along with stricter and more targeted enforcement, indicators were also selected to measure the success of the public and private sector education efforts. In this regard, S. enteritidis is also a very good indicator of the success of our education efforts. S. enteritidis is most often traced to the consumption of products containing raw eggs. According to recent surveys, products containing raw eggs or partially cooked eggs are still consumed by over half of the public. If the education efforts are successful in convincing the public to thoroughly cook or use pasteurized eggs, then the incidence of S. enteritidis will decrease.
Since foodborne illness is also traced to inappropriate food handling practices in the home, three indicators were selected that represent the practices that are most frequently improperly followed by consumers, namely refrigerating perishable food within 2 hours, and washing cutting boards and washing utensils with soap and water after contact with raw meat and poultry.
Since foodborne outbreaks are also frequently traced to inappropriate food preparation practices in the retail segment of the food industry, two indicators were selected to determine the extent to which this segment of the industry is following the latest government advice for preventing foodborne illness in FDA's model food code. Since it is important for the states to adopt the model food code in order to incorporate the most up-to-date science in its consumer protection laws, tracking state adoption of the model food code (Food Code 1993) was selected as an indicator. Finally, since the most severe cases of foodborne illness occur in institutions such as nursing homes, it is important that the states apply the food code to these institutions. Tracking the number of states that have implemented the food code for institutions was therefore selected as a separate indicator.
These ten indicators are effective measures of whether public and private sector initiatives are reducing foodborne illness. They were selected because the data needed to track them were available in the past, and resources are likely to be available to track them in the future. The status of each objective and its indicators is discussed below.
Health Status Objective: Foodborne infections
PHS Agency Assignment: Food and Drug Administration
Incidence of Infection by Foodborne
Pathogens (per 100,000)
Baseline Target
1987 1990 1991 1992 1993 1994 2000
Salmonella species
18 16 16 14 15 15 16
Campylobacter jejuni
50 .. .. .. .. .. 25
Escherichia coli O157:H7
8 .. .. .. .. .. 4
Listeria monocytogenes
0.7 0.77 0.61 0.45 0.44 0.42 0.5
Data Sources: Bacterial Meningitis Surveillance
System (BVMSS), CDC, NCID; Campylobacter
Surveillance System (CSS), CDC, NCID;
Salmonella Surveillance System, CDC, NCID.
"The incidence of listeriosis in study areas was substantially lower in 1993 than in 1989. The temporal association of this reduction with industry, regulatory, and educational efforts suggests these measures were effective."
Food and Drug Safety
Priority Area 12
Health Status Objective: Salmonella enteritidis outbreaks
PHS Agency Assignment: Food and Drug Administration
Yearly Outbreaks of Salmonella enteritidis
Baseline Target
1989 1990 1991 1992 1993 1994 2000
Salmonella enteritidis
77 68 68 59 63 44 25
Data Source: Salmonella Surveillance System, CDC, NCID.
Data demonstrate that progress has been made in the reduction of S. enteritidis outbreaks from 77 in 1989 to 63 in 1993, and 44 in 1994. Some of this progress may be attributed to adoption of on-farm risk reduction strategies (e.g., the Pennsylvania Egg Quality Assurance Program) together with focused consumer education programs.
Food and Drug Safety
Priority Area 12
Risk Reduction Objective: Refrigeration and cutting board
practices
PHS Agency Assignment: Food and Drug Administration
Consumers Using Good Food Handling Practices
Baseline Target
1988 1993 2000
Refrigeration of perishable foods 70% 72%* 75%
Washing cutting boards with soap 66% 65%* 75%
Washing utensils with soap 55% .. 75%
Data Source: Baseline: Health and Diet Survey
(HDS), USDA, FSIS; Update: Food Safety Survey,
FDA.
* Not significantly different from baseline.
The data from the 1993 FDA Food Safety Study indicate that 72% of food preparers routinely limit holding of perishable food at room temperature to 2 hours or less (compared with a 70% baseline). The data also indicate that 65% of food preparers routinely wash cutting boards with soap and water (compared with a 66% baseline). These changes are not statistically significant. The 1993 survey asked no question on washing utensils.
In addition to the above data, the survey asked four related questions: whether the respondents washed their hands after handling raw meat or poultry, how they reheated leftovers, whether they ate raw protein foods, and whether they were aware of foodborne pathogens. Responses to the first two questions showed a statistically significant decline in the safety of these food handling practices by consumers since 1988. Responses to the questions about consuming raw protein foods suggest that risky food consumption was common (ranging from over 50% who said they eat raw eggs to 5% who said they eat raw meat, such as steak tartare). The percentage of the population who were aware of specific foodborne pathogens varied greatly; over 75% had heard of Salmonella and botulism, but less than 10% had heard of Listeria and Campylobacter.
Since the 1993 survey, publicity about E. coli O157:H7 has been extensive, and much of it has mentioned the importance of thorough cooking. In addition, public and private organizations have intensified education efforts about safe food consumption and preparation practices. The publicity and education programs may increase public awareness of the dangers of foodborne pathogens and may eventually lead to behavioral change. However, past experience in changing public behavior in more healthful directions suggests that the campaigns need to be continued for years in order to make a significant difference. Food and Drug Safety Priority Area 12
Services and Protection Objective: Food protection standards
PHS Agency Assignment: Food and Drug Administration
Proportion of States and Territories
Using Food Code 1993
Baseline Target
1993 1994 2000
Institutional food operations using
Food Code 1993 0% .. 70%
States reviewing Food Code 1993 0% 80% ..
States adopting Food Code 1993 0% 2% 70%
Data Source: Listing of Confirmed Code
Adoptions by Local, State, and National
Jurisdictions, CFSAN, FDA
As a result of FDA's intensive promotion, orientation and training efforts, 80% of the states are now actively reviewing FDA's Food Code 1993, the recommended model food code.
FDA model food codes have traditionally been updated and revised every 10-15 years. Based on experience gained following the issuance of earlier model food code editions, we could expect a lag time of a couple of years followed by a period of 3-4 years when adoptions occur rapidly. The lag time represents the period necessary for jurisdictions to study and consider the provisions of the new model and to follow their legally specified administrative procedures for adoption.
Previously, approximately 80% of the states revised their requirements to be substantially equivalent to FDA's within about 8 years after publication of a new edition.
However, several factors with respect to this edition may serve to accelerate the code adoption process. These include a rapidly changing food industry combined with new approaches to food inspection and delays in the updating and reissuance of the model food code. All of these have resulted in a need for and anticipation of the new model food code edition.
To date, two federal agencies, one state, and two local jurisdictions have gone through their jurisdictions' administrative procedures and have adopted the new recommendations.
Although FDA has made good progress in working with the other federal agencies involved in food safety in institutional feeding operations, it is not yet possible to report this progress in terms of a number or percentage.