Of course, as any buffet connoisseur knows, there are some amazing buffets out there to be experienced, with food quality equal to or better than one can find at some of the very best restaurants.  There are also some very, VERY bad buffets, the type I imagine people are sent to as court-ordered punishment for misdeeds.  But regardless of whether you are enjoying a $60 lobster and champagne dinner buffet or a $4.99 roadside-kill version, there is at least one thing all buffets have in common: cross-contamination risk.  Cue the wah-wah sound.

I hate to knock one of my favorite childhood dining experiences, but the simple truth is that buffets can be risky.  They have been linked to countless incidents of foodborne illness.  Here are just a few examples:

•  In 2001, local Minnesota health departments noted a cluster of E. coli O157:H7 cases in Douglas and Pope County.  All of the cases required hospitalization due to the severity of their infections. After investigating, epidemiologists discovered that all of the case-patients had dined at the same Chinese buffet restaurant in Alexandria, MN.

•  In 2002, a large Salmonella outbreak occurred at a buffet restaurant in Spruce Pine, North Carolina.  Hamburger steak with gravy, fried chicken, and ham all tested positive for the presence of Salmonella Heidelberg.  Two employees were found to be infected with the same strain of Salmonella Heidelberg.  Both had eaten food that had been prepared at the restaurant so it was not clear if they were the source of the outbreak or if they were victims, like the patrons.

•  In 2003, multiple people, residing in several states, became ill with Shigella after their stay at a hotel in Westminster, Colorado. Several groups were affected, including hotel staff, a veterans’ group, a wedding group, and other hotel guests. The same strain of Shigella was detected among the culture-confirmed cases. The investigation determined that the illnesses were associated with eating from the breakfast buffet.

These are but a few cases where buffet dining resulted in an outbreak of illnesses.  So what is it about buffets that creates the perfect mechanism for spreading foodborne bacteria and viruses?  Again, it all comes back to cross-contamination.  Cross-contamination is the transfer of disease-causing microorganisms, such as bacteria and viruses, from one food to another.  This transfer can happen in a variety of ways.  For example, contaminated food may come in direct contact with other foods, or one food’s juices may drip contaminated liquid on another food.  Cross-contamination can also occur when a person with unclean hands touches a food item or utensil, thus spreading bacteria or viruses on their hands to everyone else who comes in contact with that food or utensil.

The self-serve format of buffet restaurants practically invites such cross-contamination issues.  Think of it this way.  In a good restaurant kitchen, the employees are well trained in proper food handling practices.  They all wear gloves, and replace them with a fresh pair any time they touch their face, hair, or anything unclean.  They wash their hands frequently, especially after each bathroom use or after touching anything unclean.  Their employers have very clear ill employee policies in place, and the employees follow those policies.

At a buffet-style restaurant, however, in addition to the usual food service employees, there is you.  That’s right, YOU are one of the food servers at a buffet, and so is every other man, woman, and child eating at the establishment.  Think of all the serving spoons and forks you must touch just to fill your plate with a delicious sampling of foods.  Now think about all the other people sitting around you who touched that exact same spoon or folk.  I know you and your family are diligent hand washers, but what about everyone else?  Ever found a serving utensil floating in the food dish?  Or even the handle sitting slightly askew and touching the food?  That is cross-contamination and you do not want to put that food in your mouth.

Other important dangers for buffet dining involve proper temperature maintenance.  Quite simply, hot foods need to be kept hot, and cold foods need to be kept cold.  Government food agencies recommend that hot foods be held at 140 F or warmer, while cold foods should be held at 40 F or colder.  Trouble arises when the food’s temperature rises above 40 F or below 140 F.  It is in this range that bacteria potentially present in small amounts can quickly grow and multiply, making it dangerous to consume and significantly increasing the risk of illness to consumers.  The presentation and serving style of buffets makes proper food holding temperature practices very difficult.

While there is no way to guarantee that your buffet dining experience will not result in a serious foodborne illness, there are a few things everyone can do to minimize their risk when dining at a buffet-style restaurant.

•  Before hitting the buffet line, and ideally after dishing up, everyone at the table should take a side trip to the bathroom for a thorough hand washing with lots of soap and hot water.

•  Do not eat foods that are not being kept appropriately hot or cold, and notify an employee who can remedy the situation if you note a problem.  

•  Do not eat foods that have obviously been sitting out for long periods of time.  

•  If you notice a utensil handle resting in the tray or touching the food, do not pull it out and use it.  Immediately notify an employee so that the food can be removed and replaced with a fresh batch of food and a clean serving utensil.

Remember, unlike pathogens that cause food to spoil, the potentially deadly bacteria and viruses that live on foods and food preparation surfaces cannot be smelled or tasted.  Prevention and safe food handling is the only way to decrease your risk of becoming ill from a foodborne pathogen.

In honor of March’s official designation as National Kidney Month, fellow Food Safety News contributing writer Dave Babcock recently published an article, National Kidney Month Kicks Off.  In his article, Babcock discusses the connection between long-term kidney health and food safety, a connection which most commonly flows from the development of hemolytic uremic syndrome (HUS) caused by toxins from foodborne bacteria like shiga toxin-producing Escherichia coli (E. coli).
 
As anyone who has been forced to suffer through ESRD can attest, the physical and mental effects it can cause are devastating.

While it is true that various treatment options presently exist, none of those options are especially desirable.  The biggest and most obvious decision for a person diagnosed with ESRD to make is whether to sustain on dialysis for as long as possible, or seek out a kidney transplant, likely enduring dialysis anyway during the waiting period.
 
If given the choice, most people with ESRD will opt for a kidney transplant.  There is evidence that a transplant can increase a person’s life expectancy up to three times longer than dialysis alone.  It can also have a much less invasive effect on a person’s day-to-day life when compared with the requirements of dialysis.  Unfortunately, the wait-time for a donor kidney is often a year minimum, but usually longer depending on a variety of factors.
 
One such wait time factor is blood type.  For example, a person with a rare blood type O will have the longest wait period, usually three to four years.  Because a patient with blood type O has antibodies against blood types A, B, and AB, it severely limits the donor pool from which a kidney may be harvested.  If the patient is fortunate, perhaps a deceased or living close relative, such as a parent or sibling over the age of 18 and who is compatible with the patient, will be able to donate a kidney.  Regardless, while awaiting a donor, an ESRD patient must undergo dialysis treatment just to survive until the transplant operation can be performed.
 
Assuming the patient survives the transplant procedure, they can then look forward to a lifetime of immunosuppressive medications, necessary to prevent their body from rejecting the transplanted kidney.  The artificial suppression of the immune system is–as nearly anyone can surmise–fraught with considerable side effects.
 
Commonly used immunosuppresants include cyclosporine, tacrolimus, meclophenalate, imuran, and corticosteroids.  Cyclosporine and tacrolimus have side effects that include increased hair growth and gum hypertrophy, as well as, ironically, damage to the kidney.   Meclophenalate and imuran are known to cause low white blood cell count and increased susceptibility to infection.  Corticosteroids can produce the undesirable Cushing’s syndrome (fatty deposits around the facial cheeks, as well as on the abdomen and back), weight gain, emotional instability, cataracts, decreased growth, softening of the bones and bone pain, hypertension, acne, and difficulty in controlling glucose levels.
 
Immunosuppressants, like those described above, are necessary for organ transplant recipients. They reduce the body’s immune response, thereby preserving the useful life of the transplanted kidney which the body would otherwise recognize as foreign and dangerous.  If this occurs, it sets off a chain of events that culminate in the body’s rejection of the kidney.  But because a healthy and timely immune system response is the body’s critical and natural defense against illness, immunosuppression therapy necessarily leads to a lifetime of heightened susceptibility to serious infection, accelerated hardening of the arteries, cancer, and chronic kidney rejection.
 
Assuming the transplanted kidney is received by the patient without complication, no transplant lasts forever.  The patient’s transplanted kidney can be expected to last about 15 years if it comes from a living donor, or about 10 years if it comes from a cadaver.  Of course, the younger the patient develops ESRD, the higher the probability that a second, or even third, kidney transplant will be required during their lifetime.  As each transplant reaches the end of its useful life, the patient will fall back into the cycle of ESRD, dialysis, an increase in kidney-related medical problems and then–assuming another kidney transplant is possible–recovery from transplantation.
 
Either decision the patient makes–transplant or dialysis–will involve dialysis treatments regardless.  As with a transplant, the patient’s quality of life is guaranteed to suffer markedly.  There are generally two modes of dialysis an ESRD patient may undergo: peritoneal dialysis or hemodialysis.
 
Peritoneal dialysis has been a major physical therapeutic method of therapy for ESRD for several years.  Continuous Ambulatory Peritoneal Dialysis (CAPD) and automated peritoneal dialysis, also called Continuous Cycling Peritoneal Dialysis (CCPD), are the most common form of dialysis therapy used in children.  In this form of dialysis, a catheter is placed in the area around the stomach.  Dialysate (a chemical bath that draws fluids and toxins out of the bloodstream) is placed into the abdomen and changed four to six times a day.  While children must often go to a medical treatment facility, adults can usually perform CAPD/CCPD at home.
 
The known compilations of peritoneal dialysis include peritonitis (infection of the fluid), which can be a major risk.  Symptoms of peritonitis include fever, excruciating abdominal pain with movement, nausea, and vomiting.  If left untreated, it usually results in death.

The other common dialysis method to treat ESRD is hemodialysis.  During hemodialysis, blood in taken out of the body by a catheter or fistula, and circulated in a machine that simulates the kidney’s natural cleansing process, removing harmful toxins and excess fluid from the blood.  While the hemodialysis process itself does not physically hurt, patients usually experience nausea and abdominal cramps as excess fluid is pulled from the body, along with fluctuations in blood pressure and heart rate.  Hemodialysis is generally performed three times a week, and takes a major time commitment–three to four hours per session is the average.
 
Beyond the transplant and dialysis complications, bone disease is nearly universal in patients with ESRD.  As a result, patients will be prone to develop bone pain, skeletal deformities and abnormal shaped bones, and have a propensity for fractures with minor trauma.  Treatment of the bone disease associated with ESRD includes careful control of the patient’s serum phosphorous and calcium levels with stringent dietary restrictions, calcium supplements, phosphorus binders, and various other bone disease-fighting medications.
 
The last major common complication of ESRD worth mentioning is anemia.  Anemia can be treated with a shot of erythropoietin given under the skin one to three times a week, or once every few weeks with a longer acting dose.  Erythropoietin is a hormone normally produced by the kidney that promotes the formation of red blood cells in the bone marrow.  In patients suffering from ESRD, this hormone ceases to be produced, thus anemia results.  Left untreated, anemia can cause severe fatigue, nerve damage, mental impairment, heart problems, and death.
 
Given the gloom and doom of this article, it is important to remember that a person’s diagnosis with ESRD is a not a death sentence.  But just because a person is fortunate enough to survive a serious shiga toxin-producing E. coli
infection and HUS–often the result of foodborne contamination–kidney damage sufficient to result in ESRD will continue to affect their life long after the E. coli  infection has passed.  The vast complications of ESRD are incredibly serious, often painful, and certain to drastically reduce a person’s overall quality of life.

If raw is generally considered to be the preferred state to consume most fruits and vegetables, the same should be true of other food products, right?

When it comes to animal products, the answer generally is “no.”  Uncooked beef, poultry, even fish, pose significant health risks of which most people are (or should be) aware.  But for other animal products, like raw milk, the dangers of “raw” are being called into question.

The most common arguments made in favor of raw milk consumption are the added health benefits not found in pasteurized milk.  So does raw milk contain some health benefits that pasteurized milk does not?  Maybe, but that’s not the concern of this article.  My concern is the risk.  Those potential benefits, which may include certain vitamins, minerals, and probiotics, are readily available from a multitude of other sources that do not have the absurdly high health risks that have been linked time after time to raw milk consumption.  Those risks include infection with Campylobacter, or worse, shiga toxin-producing E. coli–a really nasty bug.  For example, it only takes a few microscopic E. coli bacteria to produce bloody diarrhea, renal failure, and ultimately death.

Consider this true story (one of many just like it):  A young boy, then age nine, developed an E. coli O157:H7 infection in September, 2006 following his consumption of raw milk.  He was hospitalized beginning on September 8, suffering from severe gastrointestinal symptoms, including bloody diarrhea.  Shortly thereafter, he developed hemolytic uremic syndrome (HUS).  In an effort to properly treat his rapidly deteriorating condition, he was moved to multiple medical facilities, twice by life-flight.   His HUS was remarkably severe, marked by prolonged renal failure, pancreatitis, and severe cardiac involvement.  He required 18 days of renal replacement therapy.  On two occasions his cardiac problems became so severe that he was placed on a ventilator.  At several junctures, the possibility that he might not survive was very real.  Ultimately, he was hospitalized through November 2, 2006, and incurred over $550,000 in medical bills.  Renal experts have opined that he is likely to develop severe renal complications in the future, including end stage renal disease (ESRD), and require a kidney transplant.

Given the incredible harm that can result from raw milk consumption, is it good sense for a person to knowingly consume it for the few possible health benefits that can be derived from much safer sources?  As a person who is generally risk averse, I would argue that it is not good sense to make such a choice.  But what about the instance where a consumer does not realize they are choosing raw milk?

It is the locations where raw milk is available at the retail level that my concern for possible consumer confusion is at its greatest.  There are places in the United States where, for example, nostalgic, classic-styled milk bottles containing unpasteurized milk are easily found at the local grocery store, especially those stores catering to the consumer who favors organic and natural food choices.  These bottles usually have the name of the dairy from which the milk was derived, along with the fat content (non-fat, 2%, whole).  But one notation on the bottle that a consumer may not notice is the word “raw.”  The potential repercussions from inadvertently purchasing raw milk and feeding it to a person who is at-risk (including children, the elderly, pregnant women, and anyone with a compromised immune system) are enormous.  

Admittedly, the likelihood of this scenario is not equal across the United States.  The availability of raw milk for sale at the retail level is governed by a combination of federal and state laws, and at present there are many states that outright ban the sale of raw milk for human consumption.

On August 10, 1987, the FDA published 21 CFR Part 1240.61, a final regulation that mandated the pasteurization of all milk and milk products in final package form for direct human consumption. This regulation banned the shipping of raw milk in interstate commerce, and became effective September 9, 1987.  In the Federal Register notification for the final rule to 21 CFR Part 1240.61, the FDA made a number of findings, including the following: “Raw milk, no matter how carefully produced, may be unsafe.”  

Today, it is a violation of federal law to sell raw milk packaged for consumer use across state lines (interstate commerce), but each state can regulate the sale of raw milk within the state (intrastate).  Some states therefore allow raw milk to be sold.  Looking at the issue on a national level, the distinctions between applicable laws in individual states are bewildering.  In 2006, 25 states had laws outright banning the sale of raw milk intended for human consumption.  In the remaining states, dairy operations may sell raw milk to local retail food stores or to consumers directly from the farm, or at agricultural fairs or other community events, depending on the state law.  Restrictions are further varying, from specific labeling requirements, to requirements that milk only be bought with personal bottles, to the purchase of raw milk through cow shares exclusively, to permitting a sale only with a written prescription from a doctor, to sales of raw goat milk only, and to sales of a limited daily quantity only if made without advertising.  

Some states, like Washington, have strict labeling requirements which may reduce the likelihood that a consumer will unknowingly select a raw milk product from the store shelf.  By Washington state law, all retail raw milk products sold in Washington must prominently display the following label on the container’s principal display panel: “WARNING: This product has not been pasteurized and may contain harmful bacteria. Pregnant women, children, the elderly and persons with lowered resistance to disease have the highest risk of harm from use of this product.”  

Unfortunately, not all states have such a warning label requirement on raw milk products.  Some only require the words “raw” be printed somewhere on the product, while others require a statement that “raw milk is not pasteurized, pasteurization destroys organisms that may be harmful to human health.”  Personally, I think the Washington label is decent, although I prefer it define “risk of harm” to include the specific type of harm that can result from consuming the product–including renal failure and death from shiga toxin-producing E. coli strains frequently found in the feces of cows.

Because the potential for inadvertently selecting raw milk exists at the retail level, I implore you to please pay extra attention while selecting your milk at the local grocery store if you live in a state where raw milk is legal to sell.  Look carefully at the product for words like “raw” and “unpasteurized.”  And if you are a person who is deliberately choosing to consume raw milk or raw milk products in spite of the abundant scientific evidence and federal, state, and local health agency-investigated outbreaks that have linked devastating human illness to the consumption of raw milk, then please do not give it to those most at risk–children, the elderly, pregnant women, and any person with a compromised immune system.  The
potential for devastating he
alth consequences is not worth the possible health benefits that are available from many other, much less dangerous sources.

I have taken it upon myself to write to you personally with the intent of informing you of a most important fact.  This is a fact about which you may not be fully (or at all) aware, and the potential consequences regarding this fact are great, even deadly.  Oh, and it directly involves you and every member of your family.  So without further rambling, here it is: you are now considered a “kill step” and should proceed accordingly.

No, I did not just insult you.  I am, of course, referring to your role in the manufacturing process of prepared, but not ready-to-eat foods.  Didn’t you get the memo?

For the uninitiated, a “kill step” is the term typically used to describe a point in the food manufacturing process where potentially deadly pathogens are eradicated from the product (usually by killing the pathogen).  Traditionally the “kill step” has involved cooking, pasteurization, pathogen-killing washes, irradiation, etc.  One commonality among these techniques was their timing in the manufacturing process.  The step occurred before the product was sold to retail establishments, put on the store shelf, and ended up in your refrigerator or freezer.  This policy operated from the understanding that it was the manufacturer’s responsibility to ensure that the food product you purchased from the store was free of adulterants, like pathogens, that could make you sick or even kill you.

But outbreak after outbreak has shown that food companies are not doing a very effective job of achieving this standard, and that something else had to be done to achieve food safety goals while also keeping the cost as low as possible.  This is where you now come in.

Imagine it this way:  you purchase a new, top of the line car and decide to take your family on a weekend road trip to rev the engine and see what it can really do when out on the open road.  As you cruise down the highway, you notice the cars ahead in your lane slowing and depress the brake pedal to match their speed, only to have the pedal snap off at the last moment, leading to a horrible car accident.  Now imagine if the car company said it was your responsibility to perform a final weld on the brake pedal before you used it (didn’t you read the manual front to back, dummy?)  In other words, ensuring the safety of your brand spanking new purchase should fall on your shoulders, not theirs.

In essence, the shifting of responsibility is what this new consumer “kill step” is all about.  A study published this past month in the British Food Journal by researchers from Kansas State University highlights the potential for grave consequences that can occur when the responsibility for effective “kill steps” are shifted from the manufacturer to the end user.

The study, titled Self-reported and Observed Behavior of Primary Meal Preparers and Adolescents During Preparation of Frozen, Uncooked, Breaded Chicken Products, concluded that safe handling and cooking of frozen, uncooked, breaded chicken rarely occurs, in spite of the preparer’s intentions and perceptions about their behavior.  

The researchers used video surveillance equipment to study participants in two model kitchens as they prepared frozen, uncooked, breaded chicken products.  These products were specifically chosen because of the similarity to products implicated in numerous past foodborne illness outbreaks.  The results–noted after monitoring the 41 adult and adolescent consumers prepare the products to a complete, ready-to-eat state–were hardly surprising.

With regard to thermometer use, only 3 of the 41 participants used the digital or dial read food thermometer correctly.  The importance of proper, accurate thermometer readings when cooking raw foods cannot be overstated.  Heating to 165 degrees Fahrenheit in the center of the product is necessary for the end-consumer cooking process to be an effective “kill step.”

Further, assuming the consumer is actually using the thermometer correctly, are the temperature readings even accurate?  A 2004 study by the Hospitality Institute of Technology and Management, titled Inaccuracy of Food Temperature Measurement with the Bimetallic Coil (Dial) Thermometer, answers that question with a resounding “maybe.”  

For bimetallic thermometers–the type commonly used by cooks–it must be fully inserted into the food item so that the complete length of the coil is in the food.  “Then, it registers the average temperature from the tip to the top end of the coil.  Therefore, if one end is 125 degrees Fahrenheit, and the other end is 175 F, the thermometer indicates 150 F.”  Even more serious is the thermometer’s inherent design flaw for certain foods.  Because the entire coil needs to be inserted into the food item, bimetallic thermometers are “virtually impossible to accurately measure thin foods such as chicken breast, a hamburger, or scrambled eggs.”  After conducting numerous tests on various foods, such as meatballs, hot dogs, chicken breasts, and hamburgers, the study found that the bimetallic thermometer readings were between 10 and 48 F below the actual center temperature of the food when measured with a more accurate tip-sensitive thermometer.  

Setting aside the myriad issues with measuring the actual temperature of the food, how about the effectiveness of the instructed cooking directions contained on the package of prepared, but not ready-to-eat foods?  

New York Times writer Michael Moss wrote about this very issue in his article, Food Companies Are Placing the Onus for Safety on Consumers.  Attempts by staff at the newspaper to follow the directions on several different types of frozen meals, including ConAgra Foods’ Banquet pot pies, “failed to achieve the required 165-degree temperature.  Some spots in the pies heated to only 140 degrees even as parts of the crust were burnt.”  When they called the ConAgra consumer hotline listed on the back of the packaging, the operator informed them that “claims by microwave-oven manufacturers about their wattage power could not be trusted.”  

In other words, instructions telling the consumer to cook the product, for example, 10-12 minutes in a 750 watt microwave oven, or 8-10 minutes in a 1,000 watt microwave oven, are unreliable.  Additionally, how long exactly are you supposed to cook it?  10 minutes? 11 minutes? 12 minutes?

But the most compelling argument for not relying on the consumer as a “kill step” comes from Jim Seiple, a food safety official with the makers of Swanson and Hungry-Man pot pies–“The pot pie instructions have built-in margins of error, Mr. Seiple said, and the risk to consumers depended on ‘how badly they followed our directions.'”

If consumers are the newest craze in “kill step” technology, the food companies utilizing our “services” had better be damn sure that we know of our role, and have the complete understanding, training, and tools for every aspect of the process to ensure its efficacy in the real world.

The above-mentioned recent studies and articles back up what I have long feared to be true–consumers are not being made aware of their foisted-on “kill step” duties, and in the real world of busy kitchens, variable watt microwaves, and non-English reading families, it is simply a horrible idea.

Let me be clear, I do not believe consumers should be ignorant about their role in food safety or the reasonable steps each of us can take to reduce the chances of contracting a foodborne illness.  But making the end consumer a “kill step” in the food manufacturing process is a dangerous idea, one fraught with so many variables and potentials for error that it is ludicrous to rely on it.  Food manufacturers of prepared, but not ready-to-eat foods need to take back their “kill
step” and put it in their ow
n manufacturing process so that the product sitting in the refrigerated isle of our local grocery store is safe, free from pathogens, and ready for human consumption.

The Oklahoma State Department of Health and the Mayes County Health Department investigated and concluded it was a foodborne point-source outbreak originating from a restaurant, Country Cottage, located in the town of Locust Grove, Oklahoma.  The foodborne transmission of the E. coli bacteria occurred between August 15 and August 24, 2008, and many of those who were unfortunate enough to have dined at the restaurant during this inopportune window became ill–314 known cases, 72 in-patient hospitalizations, and one death.  

Those figures represent just the known victims.  According to the Centers for Disease Control and Prevention (CDC), for every one culture-confirmed, health department-linked illness in an E. coli outbreak, there are approximately 20 additional people who were actually sickened in the outbreak, but for a host of reasons their illnesses are not reported.  Thus it is more accurate to list the number of victims for this outbreak as 6,280–huge.
 
Not only was this outbreak physically and emotionally devastating for those affected by it, but there was an incredible dollar cost as well.  For example, fourteen of the 314 victims in the Country Cottage E. coli outbreak amassed medical bills that cumulatively totaled over two million dollars.

Why am I telling you about this particular outbreak?  Because the bacteria that caused the calamitous results described above was E. coli O111, and, according to the United States Department of Agriculture’s (USDA) Food Safety and Inspection Service (FSIS), this strain of e. coli is NOT an adulterant.  

That’s right, according to the federal agency tasked with overseeing the safety of our nation’s supply of meat, poultry, and processed egg products, this particular strain of E. coli is not an “impurity” or “an additive causing an undesirable effect.”  Excuse me, but if death and permanent bodily injury directly caused by this nasty pathogen does not count as an “undesirable effect,” what does?

Please allow me to explain.  

Escherichia coli O111 belongs to a family of bacteria known as Shiga toxin-producing Escherichia coli (or STEC).  STEC infections are the leading cause of bacterial enteric infections in the United States.  According to the Morbidity and Mortality Weekly Report released by the Centers of Disease Control (CDC) on October 16, 2009, STEC infections cause approximately 100,000 illnesses, 3,000 hospitalizations, and 90 deaths annually in the US.  

The primary symptom of an STEC infection is acute diarrhea that is often bloody.  Further, approximately 8% of people diagnosed with E. coli infections develop a life-threatening condition called hemolytic uremic syndrome (HUS), the most common cause of acute kidney failure in infants and young children–leaving the mildly unlucky ones with future sequelae that may include hypertension, proteinuria, or low glomerular filtration rate.  The severely unlucky are left with long-term extra-renal damage, especially of the pancreas or brain, and severe kidney damage that requires chronic dialysis and future kidney transplant.

In the report, the CDC explicitly recognizes the multifarious significance of properly identifying STEC infections, highlighting that:

Prompt, accurate diagnosis of STEC infection is important because appropriate treatment early in the course of infection might decrease the risk for serious complications such as renal damage and improve overall patient outcome. In addition, prompt laboratory identification of STEC strains is essential for detecting new and emerging serotypes, for effective and timely outbreak responses and control measures, and for monitoring trends in disease epidemiology.

The primary focus of the CDC’s report and recommendations pertain to uniform STEC testing by clinical laboratories, including the recommendation that ALL patients presenting to medical facilities with acute diarrhea be routinely tested for both E. coli O157:H7 and non-O157 STEC.  Doing so would allow 1) identification of additional STEC infections and further detection of other STEC serotypes, 2) early diagnosis and an improved outcome for those infected, and 3) prompt outbreak detection by investigating health agencies.  The CDC recognizes the importance of these benefits, but apparently FSIS does not.

In 1994, following the infamous Jack in the Box E. coli O157:H7 outbreak that killed four children and injured another 700 individuals, FSIS acted boldly and appropriately by declaring E. coli O157:H7 to be an adulterant.  This was a significant policy shift for an agency that had not previously considered pathogens in raw meat and other products under its purview to be adulterants.  Once declared as an adulterant, FSIS had the authority to regulate the presence of this foreign pathogen in the various foods under its authority.

But since that time, despite countless scientific studies, and non-O157 STEC outbreaks and the related devastation they have caused, only one very particular serotype of the larger STEC family, E. coli O157:H7, is considered an adulterant by FSIS.  Declaring E. coli O157:H7 an adulterant while ignoring the more than 150 other STEC serotypes associated with outbreaks and illness is akin to releasing a seasonal flu vaccine that protects against only one influenza virus, while leaving out the other known circulating seasonal flu viruses that are equally as dangerous.  

In other words, it is not a complete waste of effort but certainly devoid of logic and purpose.  This illogical policy stance is especially true given the fact that FSIS went so far as to hold a public meeting in 2007 on the health significance of non-O157 STEC, and stated “growing awareness that STECs other than E. coli O157:H7 cause sporadic and outbreak-associated illnesses.” (emphasis added).


There is a simple truth being ignored by FSIS here:  non-O157 strains of E. coli can and frequently do produce devastating human illnesses that are on par with–or even more severe than–O157:H7 infections.  Declaring those non-O157 strains an adulterant is the only reasonable, thoughtful, and sane response to the growing chorus of voices seeking change.  I implore FSIS to face facts and take the regulatory steps necessary to significantly lessen the chances that yet another non-O157 E. coli outbreak occurs or goes undetected.

School meal programs are a coordinated effort between Federal agencies, state education agencies, and local food authorities, which operate in school kitchens and cafeterias across the nation.  The collaborative effort that goes into the purchasing, distribution, and preparation of food for our school children is a complex and daunting task when we look at it on a global scale.

I think we can all agree that establishing an effective and efficient food product recall notification system for the general public is a task even more complex and daunting.  But how about a notification process between the federal agencies tasked with food safety oversight and the schools that participate in the federal government’s school meal programs?  It should theoretically be easy to notify a school that it might be serving its students E. coli-contaminated taco meat or peanut butter sandwiches with a dash of Salmonella from foods procured through the federal program.  A report by the United States Government Accountability Office (GAO), also known as the investigative arm of Congress, however, concludes that these federal agencies are making it as difficult and inefficient as possible to get such information to the people who need it – schools.  

Following a series of recent, high-profile foodborne illness outbreaks, the GAO launched an investigation into the federal school meal program as it relates to food recalls.  You can read the full report and final conclusions here (PDF, 46 pages).

If you are at all like me, you will quickly lose count of the number of times you let out an audible, “you’ve got to be kidding me!”  While the GAO’s ultimate conclusions and recommendations for the Secretary of Agriculture are certainly laudable and worthy of implementation, one cannot help but sit in bewilderment that these recommendations were not being carried out already.  

Before I comment on some of the findings and recommendations in the GAO’s report, it is helpful to have a basic understanding of the federal oversight process for foods served throughout the nation’s school systems.  The U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS), is responsible for overseeing federal school meal programs.  These programs provide food products to the schools through the federal commodity program, which accounts for about 15 to 20 percent of the food served in school-provided meals.

The USDA’s Food Safety and Inspection Service (FSIS) is responsible for establishing regulations to ensure the safety of the nation’s supply of meat, poultry, and processed egg products, while the U.S. Department of Health and Human Services’ Food and Drug Administration (FDA) is responsible for nearly all other food items.  It is, quite obviously, a highly fractured and inefficient system that has led many to conclude that a complete overhaul is the only true fix.

But in discussing the current structure, what immediately jumped out at me was the realization that the agencies in possession of nearly all necessary and relevant information about potentially contaminated foods–USDA and FDA–are really awful at sharing that information with the very people they are tasked with protecting.  For example, FSIS has in place procedures that allow it to provide immediate notice to FNS when there is an investigation pertaining to possible contamination of FNS commodity food products.  But despite being USDA’s sister food protection agency, FDA has no such similar procedures in place.  Why does it take a GAO investigation to bring such a glaring deficiency to the FDA’s attention?

Proper notice is the first step in the entire recall process and will ultimately determine whether or not a school is informed that it is serving its students food items under serious investigation for contamination.  Rest assured Joe Public, because FDA is on it now.  FNS and FDA are currently developing a memorandum of understanding on this specific deficiency that will be issued…sometime.  Excuse my cynicism, but this is not some extraneous procedure–this is a central problem that needs immediate action today, not more talk to schedule a meeting to discuss some possible changes to maybe add to a memo at some possible point in the future.  Set a deadline, get it accomplished, and do it now.  It’s your job.

Another frustrating problem lies with a potentially useful and efficient tool at FNS’s disposal.  FNS has the ability to issue administrative product holds, essentially pulling a product from use within FNS’s school meal programs, when it is notified of an initial food recall or upon notice of an investigation by USDA or FDA into possible food product contamination.  This tool would be especially useful because–as both USDA and FDA are well aware–ensuring that food recalls are carried out effectively and efficiently is especially crucial when those foods are going to young children who have a much higher risk of suffering serious health complications due to foodborne illness.  So when does FNS issue these administrative holds?  Great question–it seems no one, including FNS itself, has any idea.  It turns out USDA has given FNS no factors or criteria to consider when attempting to determine whether such an action is advisable.  Instead, FNS relies solely on the recall notices eventually issued once an outbreak is in full effect.  In other words, once people have begun consuming the product and are now infected with a potentially deadly pathogen.  

This isn’t rocket science.  The best time to stop an outbreak is before it occurs, and the only way to effectively do that is to use the tools at your disposal–like administrative holds–that stop products from being distributed or used while still in the investigation phase, not issue recall notices after the contaminated product has made its way into the bellies of our school children.

Speaking of recall notices, this brings me to yet another “duh” revelation in the GAO’s report.  As things currently stand, when a federal school meal programs commodity product is placed under investigation for suspected contamination, USDA or FDA notifies FNS, which in turn notifies individual states, which then notify the schools.  At least this is how the process is supposed to work.  But as the GAO report makes clear, often times FNS will either wait to provide recall information to the states until a recall notice has already been issued, meaning days or weeks can pass before a state is fully informed, or FNS will provide incomplete and inaccurate information to the states, making it needlessly difficult, if not impossible, for the schools to identify the food products potentially in their possession subject to the recalls.   

Even if FNS timely provides information to states, it does not follow through to ensure that information is properly communicated to the schools.  To somewhat address this glaring deficiency, FNS has tried communicating the food recall information directly to the schools via an e-mail notification system.  But as with nearly everything the government does, the process is made so needlessly cumbersome as to be ineffectual.  For example, initially FNS limited the number of characters of text in the notice to 300.  That is only slightly more than the characters allotted for a text message!  Not surprisingly, the notices lacked any product names, or states or schools that received the recalled product.  To its credit, FNS has since increased the number of characters to 1000, but why limit the number in the first place?  Finally, the whole e-mail system requires the end user, presumably the school official designated as the federal school meal program liaison, to register through FNS’s website, and then later confirm the registration.

This voluntary registration process is ridiculous.  FNS should require that each school participating in its federal school meal programs designate at least one primary person and one backup person as an FNS programs liaison.  Those liaisons should be required to provide an e-mail address and telephone number through which FNS would automatically send e-mail and computerized telephonic recall notification.

Once the database is established, FNS must actually use it.  As the GAO report reveals, in the recent Peanut Corporation of America Salmonella outbreak, the FNS e-mail system was not used until a full two days after the FDA had already publicly announced the expanded recall.  Once again, a potentially useful tool went to waste.  As we all know, the simple act of sending an e-mail is, well, simple.  Not to mention that it is also quick and cost-efficient.  Given the rapid transition to instantaneous communication, there is simply no reason or excuse for FNS’s snail-mail approach to providing food recall notices to our nation’s schools.

I’ll just end this rant with a classic contract law axiom that struck me as particularly apropos–time is of the essence.  Each moment wasted in the chain of notice is yet one more opportunity for contaminated food to make it further down the line and onto the lunch tables of our nation’s school children.  The GAO report is full of excellent and worthy recommendations, but there really should not have been a need for the investigation in the first place.  Creating an efficient and effective recall notification system for the foods that are served to our nation’s children should have been accomplished long ago.  A remedy for this problem must be done right, and done right now – before one child’s guaranteed breakfast or lunch leads to a lasting reminder of the failures of our nation’s food safety system.