March 3, 2014. Dear Dietary Guidelines Committee:

March 3, 2014 Dear Dietary Guidelines Committee: The National Restaurant Association (the Association ) appreciates the opportunity to provide comments to the committee regarding approaches the industry has taken to ensure the safety of foods served in restaurants and other foodservice establishments. Founded in 1919, the Association is the leading business association for the restaurant industry, which comprises 960,000 restaurant and foodservice outlets. The Association represents more than 435,000 member restaurant establishments comprised of tableservice, quickservice, chains, franchisees, independents, institutional foodservice providers and allied members. Food and healthy living are priorities for our every-growing industry, which employs approximately 13.1 million people. Food safety is an on-going commitment for the restaurant industry, protecting customers from foodborne illness. We would like to bring to your attention for inclusion in the Nutrition Evidence Library numerous studies that have been published regarding food safety and the restaurant industry. Foodborne Disease: Its Occurrence and Sources Pathogens are known to cause an estimated 9.4 million cases of foodborne disease annually in the United States. During 2009-2010, a total of 1527 foodborne disease outbreaks were reported, resulting in 29,444 illnesses, 1184 hospitalizations, and 23 deaths. Among the 790 outbreaks with a single laboratory-confirmed etiological agent, Norovirus was the most commonly reported agent, accounting for 42% of outbreaks (CDC, 2013). Salmonella infections was second, involved in 30% of outbreaks. Since approximately half of foodborne illness occurs from retail food establishments, it may be expected that consumers often associate foodborne illness with food served outside the home. In a 2002 phone interview study, 22% of individuals who had recently been ill believed the source of their gastrointestinal illness was a meal eaten away from home. (Green et al, 2005) However, the fact is that The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) report improvements in food safety for five of the six major pathogens, including Shigella and E.coli. (CDC, 2013) It is also a fact that of the 1527 foodborne disease outbreaks in 2009-2010, less than half (43%) occurred in a restaurant; nine percent occurred in a private home. Of the total number of outbreaks, 6% were in quick service restaurants, 32% in sit-down restaurants, and 5% in other types of restaurants (or the type of restaurant was not known). One percent of the outbreaks occurred from food prepared in grocery stores, 0.1% in hospitals, 0.4% in nursing homes or assisted care facilities, 0.9% in schools, and 1

0.4% in the workplace. 0.4% of outbreaks occurred for food prepared at banquet events. (CDC, 2013) Food workers can be a source for transmission of pathogens that cause foodborne disease, but food workers are identified as the cause for foodborne disease in only one in five cases. (CDC, 2006). Further, less than half (46%) of outbreaks in which food handlers were implicated occurred in food service establishments. (Todd et al, 2008) Food Safety In Restaurants Has Improved In Recent Years CDC tracks foodborne disease incidence through a tool called FoodNet. CDC reports a reduction in foodborne disease from 1996 to 2010 (CDC, 2013), with specific reductions in: Shigella 57% Yersinia 52% STEC E.coli 44% Listeria 38% Campylobacter 27% Among the six major pathogens tracked, five decreased while one, Vibrio foodborne disease, increased by 115%. There was an overall decrease in the six major pathogens by 23%. Norovirus is not tracked by FoodNet, since there is no test to detect it. In 2010, CDC reported a decrease in overall estimated foodborne disease from 76 million illnesses with 5000 deaths to 48 million illnesses with 3000 deaths. FDA tracks foodborne disease in retail establishments through their Retail Food Risk Factor Study. Their most recent results show improvements in specific risk factor behaviors in fast food and full service restaurant establishments; showing better overall compliance, fewer instances of poor personal hygiene, and fewer improper holding/times and temperatures for the period between 1998 and 2008. These data suggest that food from restaurants is safer today than a decade ago. There is always more work to be done; however, the information that is available suggests that our food supply is getting safer, especially from foodservice establishments. Effect on Foodborne Disease of Restaurant Practices Relative to Managing Sick Food Workers There has been considerable interest in recent years regarding the role of sick food workers in relationship to foodborne disease. We believe that the attention on this issue is disproportionate to its role in foodborne disease occurrence. 2

Importantly, there are regulatory provisions that prevent sick employees from handling food. These regulations are in place through FDA s Food Code and are enforced through state and local regulatory officials. The FDA Food Code requires that a sick employee report to the Person in Charge (PIC) information about their health and activities that relate to diseases that can be transmitted through food. The PIC is required to exclude or restrict employees from work assignments where there is risk of transmitting a disease. In a 2011 research report by Sumner and his team, published in the Journal of Food Protection, 12% of interviewed food workers said that they had worked two or more shifts while experiencing vomiting or diarrhea in the previous year. (Sumner et al, 2011) This number is in sharp contrast to the number reported by the Restaurant Opportunities Center United (ROC), a group co-founded by labor activist, Saru Jayaraman. Based on their surveys of food establishment employees and employers from 2003 to 2010, 63% of workers reported cooking or serving food while sick. (ROC, 2010) Sumner and his team (Sumner et al, 2011) also reported on the factors affecting whether or not a food handler works while ill. Volume of the business had the strongest association with working while experiencing vomiting or diarrhea. Higher-volume restaurants are more likely to have employees working while sick; reasons offered included that high-volume restaurants are busy and workers are needed to serve customers. Also, workers may be reluctant to call in sick in order to not leave their colleagues short-handed. Research studies have evaluated the role of sick leave policies on foodborne illness. The Sumner research team (2011) showed that employees were more likely to work while sick with vomiting or diarrhea in restaurants that had no policy requiring sick workers to tell managers they are ill, compared with restaurants that had such a policy. They also showed that employees in restaurants with a policy requiring a doctor s note from workers returning to work after an illness were more likely to have worked while sick with vomiting or diarrhea than were employees in restaurants without such policies. Researchers have also considered the role of paid sick leave on foodborne illness. The CDC reports that of 154 foodborne disease outbreaks they investigated, about one-third (34.9%) of workers received paid sick leave. (Delea et al, 2008). While the Sumner team (Sumner et al, 2011) also found that workers said they would be likely to have worked while suffering vomiting or diarrhea if they had paid sick leave, if a paid sick leave policy is in place, such practice is not likely to prevent all sick workers from transmitting disease. It is difficult for managers to identify food workers who may be excreting food pathogens, even when those workers report their illness. Workers shed pathogens during the prodrome or early phase of illness before symptoms appear, can be long-term excretors, or be asymptomatic carriers. Some convalescing individuals excreted Salmonella for 102 days. (Todd et al, 2008) Due to these circumstances where pathogens may be transmitted without typical signs of disease, exclusion policies -- paid 3

or unpaid -- may have limited effectiveness in preventing transmission of foodborne illness in food service settings. Sick employees are not primary vehicles for transmission of foodborne disease in food service operations. FDA recognizes three key risk factors for foodborne disease: (1) Poor personal hygiene (2) Improper holding of food (3) Contaminated food surfaces and equipment Proper hand washing is the primary means to prevent contamination of food from food handlers. This situation is valid regardless if a food handler is well or ill. Practices In Place to Ensure Foodservice Managers and Employees are Trained in Food Safety Each day, the restaurant industry s 13 million employees serve meals to over 135 million Americans. For this reason, food safety is a primary concern for the restaurant industry. Assuring safe, quality food has been at the core of the National Restaurant Association s mission since its founding in 1919. The National Restaurant Association developed ServSafe, a national food safety training program for foodservice employees and managers. The standardized course, offered in multiple languages in a classroom format or online, includes food safety best practices developed by specialists from regulatory agencies, academia, and the foodservice industry. ServSafe materials reflect the latest science, research, and most recent edition of the FDA Food Code. The certification examinations are accredited by ANSI-CFP (American National Standards Institute- Conference for Food Protection). More than 5 million foodservice professionals have been certified through the ServSafe Food Protection Certification Examination. ServSafe training and certification is recognized by all 50 states; more federal, state and local jurisdictions than any other food safety certification. Training is available for ServSafe Food Protection Manager and ServSafe Food Handler. The National Restaurant Association is Committed to Support Certification of Food Protection Managers The National Restaurant Association agrees with regulatory authorities that foodservice managers should acquire a substantive training foundation in safe food handling practices. Such training helps to: protect consumers by reducing incidents of foodborne illness, 4

increase consumer confidence in the safety of their restaurant meals, promote ongoing business success within local communities. Currently 24 states plus the District of Columbia have statewide mandates that require restaurant managers to be certified in safe food management techniques. An additional 10 states have at least one city or county jurisdiction that mandate that restaurant managers must be certified in safe food management techniques. A Certified Food Protection Manager (CFPM) has the knowledge, skills and abilities necessary to protect the public from foodborne illness. Since managers in a foodservice facility oversee all aspects of the operation and employees, it is imperative for them to have the strongest possible background in food safety procedures. Data from CDC and FDA studies confirm that the presence of a Certified Food Protection Manager has a positive impact on reducing incidents of foodborne illness. For example, a 2009 FDA study compares rates of inspection compliance for establishments with vs. without a CFPM: Segment Compliance rate with Compliance rate without CFPM CFPM Full Service 70% 58% Delicatessens 79% 64% Produce Markets 86% 79% Seafood Markets 88% 82% The FDA further reports that, with the implementation of a CFPM requirement, overall compliance improved over the three data collection periods in all nine of the establishment types that were studied. These positive results compelled the FDA to propose that having a CFPM should become common industry practice (FDA, 2011). In the U.S., there are nearly 1,000,000 foodservice establishments in the country with varying levels of training in food safety. The National Restaurant Association believes there are benefits to consistent food safety training for foodservice managers, including professional certification standards in safe food handling practices of managers. In order to accomplish this goal, the National Restaurant Association encourages that managers of a foodservice facility become Certified Food Protection Managers. The NRA supports states that desire to adopt a statewide standard for manager certification programs that: have been accredited by the American National Standards Institute (ANSI) under the Conference for Food Protection (CFP) Standards for Accreditation of Food Protection Manager Certification, have appropriate and effective training delivery mechanisms, facilitate consistent and creditable training for foodservice managers. The industry is prepared to assist with the facilitation of this training by working with the more than 3000 state and local entities to implement an easy to use, comprehensive training program that covers the critical elements of food safety. 5

The National Restaurant Association has partnered with FDA to increase Food Protection Manager Certification. This partnership aligns directly with our Food and Healthy Living Imperative to increase food safety in the restaurant industry and improve consumer awareness about food safety. The National Restaurant Association is proud of our role in promoting food safety through our role in food safety training, including the ANSI ASTM 2659-accredited ServSafe Food Handler training program. The National Restaurant Association has been actively promoting food protection manager certification by: Educating the industry and the public about the importance of food safety and importance of food safety training and certification; Promoting the adoption of the requirements of the 2013 FDA Food Code requiring one certified food protection manager per establishment; Releasing the 6 th edition of ServSafe Essentials and ServSafe Coursebook in 2012, which communicates the importance of certifying foodservice managers. The 6 th edition of ServSafe Essentials has been refocused to cover only the key information that empowers a manager to protect an establishment from foodborne illness. In doing so, we create a greater standard for food protection in the nation. The quality of the training program will create a more knowledgeable food protection manager and attract more organizations to certify their managers; Developing white papers, case studies, and articles to help foodservice operations, consumers and trade organizations in managing food safety training and certification; Developing a regulatory database for tracking: (1) regulations at the state, county, city and local/tribal levels for food protection manager certification, (2) the version of the FDA Food Code (including any exemptions) a regulatory agency is using, (3) if HACCP requirements apply, (4) food handler requirements, (5) allergen regulations, and (6) other data important to NRA members and ServSafe customers. We believe having data on the types of regulations that are in place will aid restaurants in identifying the need for a certified food protection manager and this will increase manager certifications; Promoting National Food Safety Month. Each September, we focus resources, media, and other types of outreach efforts to educate about food safety topics and provide free food safety resources to the industry; including encouragement for certification of food safety managers. The number of certified ServSafe managers has almost doubled since 2007. A total of 266,400 managers were certified through ServSafe in 2007, and the number has steadily increased over 6

recent years. In 2013, 470,940 managers were certified, up two percent compared with 2012, which was five percent higher than 2011. The National Restaurant Association remains committed to increasing the number of well trained and certified food safety managers. The organization is also committed to enhancing the food safety knowledge base for all food handlers through ServSafe and other certification programs. Additional Food Safety Resources As the Committee has expressed an intent to consider matters of food safety as part of your recommendations for the 2015 Dietary Guidelines for Americans, we encourage the Committee to consult additional experts in food safety. Specifically, we urge the Committee consult with Dr. Michael Doyle of the University of Georgia and Dr. Roger Clemens of the University of Southern California. Conclusion The National Restaurant Association welcomes the opportunity to share information with the 2015 Dietary Guidelines for Americans Advisory Committee about the safety of foods served in restaurants across the United States. We urge the Committee to consider the information and resources shared that provide an accurate description of the incidence of foodborne disease from restaurant foods, improvements in the safety of foods served in restaurants, the research data regarding the role of sick food handlers in foodborne disease, and the types of training required and utilized by foodservice establishments to ensure workers and managers have adequate knowledge about food safety and prevention of foodborne disease. Respectfully submitted, Joy Dubost PhD RD CSSD Director of Nutrition, National Restaurant Association Catherine Adams Hutt, PhD, RD Consultant to the National Restaurant Association 7

References CDC. (2006) Surveillance of foodborne disease outbreaks United States 1998-2006. MMWR. 55:SS-10. CDC. (2013) Surveillance of foodborne disease outbreaks United States 2009-2010. MMWR. 62(03);41-47. Delea KC et al (2008) Intl Conf on Emerging Infectious Disease, Ann Meeting, March. FDA (2011) 10-year study, cited in FDA Retail Food Safety Initiative Action Plan, September http://www.fda.gov/food/foodsafety/retailfoodprotection/retailfoodsafetyinitiative/default. htm Green L, Selman C, Scallan E, Jones TF, Marcus R, & EHS-Net Population Survey Working Group (2005) Beliefs about Meals Eaten Outside the Home as Sources of Gastrointestinal Illness J Food Protect 68(10):2184 Restaurant Opportunities Center United (2010) Serving While Sick. (Sept 30, 2010) http://rocunited.org/roc-serving-while-sick/ Sumner S, Brown LG, Frick R, Stone C, Carpenter LR, Bushnell L, Nicholas D, Mack J, Blade H, Tobin-D Angelo & Everstine K (2011) Factors Affecting Food Workers Working while Experiencing Vomiting or Diarrhea J Food Protect 74(2):215 Todd E, Greig JD, Bartleson CA & Michaels BS (2008) Outbreaks Where Food Workers Have Been Implicated in the Spread of Foodborne Disease. Part 5. Sources of Contamination and Pathogen Excretion from Infected Persons. J Food Protect 71(12):2582 8