One of the most difficult challenges in the safe operation of a retail foodservice establishment is preventing employees from working while sick. The greatest risk (from both the hazard and probability) is due to employees working while sick with the infectious disease norovirus. In fact, the most common cause of foodborne illnesses in foodservice establishments in the United States, norovirus, occurs due to significant challenges to detect and then exclude all employees who are sick because:
• A manager often cannot tell when an employee is sick via signs of illness if they do not tell them they are sick (signs of illness can be observed by others while symptoms must be measured or reported) unless they physically vomit in the restaurant or you observe they are going to the restroom two to three times an hour (a definite sign of possible illness).
• Employees can be sick but asymptomatic (up to 2 weeks after being sick as well).
• Employees may work while sick because they are not trained or provided any incentive to report illness, and/or because they need the money and cannot afford to take unpaid leave.
• Employees who are excluded from one restaurant will work at another restaurant (i.e., are employed by multiple businesses).
• Employees (when discovered sick and excluded) may have already infected other employees as they worked while asymptomatic, and if a wellness check is not performed at each shift every day, these newly infected employees will continue to work and infect others.
Now, during this coronavirus pandemic (COVID-19), the challenge of preventing virus transmission by screening and exclusion of sick employees is even greater. The impact of this new normal goes beyond whether restaurants can remain open, but even as they do, will the customers and employees feel safe from infectious diseases like COVID-19 or norovirus? It is probably now a business continuity need in the foodservice industry to perform employee screening and virus mitigation rather than an optional Standard Operating Procedure (SOP).
Viral infectious diseases like norovirus or COVID-19 are difficult to control—the viruses come into a restaurant via employees, are persistent, and are highly contagious to other employees and customers directly via surface or aerosol transmission, even in very small amounts. The two most effective controls for the prevention of both of these viral diseases in foodservice are similar:
1. The means to more efficiently reduce the risk of employees working when sick (employee screening/wellness checks)
2. The means to ensure virus mitigation using personal hygiene and environmental contamination controls (including engineering controls) to reduce the risk of virus transmission to both employees and food
The best means to ensure these processes are performed and the related hazards are controlled is by properly establishing a Process Hazard Analysis and Critical Control Points (HACCP)-based food safety management system (FSMS), whereby all the hazards are identified and controls established, employees are trained on the SOPs and managers are trained to manage them, the controls are monitored daily, and when a control is not working or absent, it is corrected in real time to significantly reduce both foodborne illness and COVID-19 transmission.[1] Development of a Process HACCP-based FSMS in a retail foodservice business based on U.S. Food and Drug Administration (FDA)’s Food Code Annex 4 on Active Managerial Control[2] is described in more detail in a new book.[3] This FSMS can also be used to include the new controls necessary to prevent COVID-19 with just a few modifications while also keeping the restaurant safe from foodborne disease outbreaks.
Viruses are often first transmitted in foodservice facilities via transmission from employees’ hands to environmental surfaces like door handles or handwash sink faucet handles.[4] The viruses are then transmitted to other employees unknowingly when they touch these common high-touch surfaces, which then leads to cross-contamination of food, often even when the employee is wearing foodservice gloves.[5] Therefore, the foodservice business’s FSMS must include the SOPs to train and screen employees for illness in an attempt to prevent this first transmission event. The FSMS must also include the SOPs for virus mitigation, which include personal hygiene controls and environmental contamination controls.
Always check with your local health department to coordinate health-related requirements to operate a foodservice business and to ensure timely and accurate information on operations. This is especially important during a sustained transmission of COVID-19 in your local area.
Employee Screening/Wellness Checks
For many years, FDA has recommended that employees be trained and screened about/for signs and symptoms of foodborne illnesses to enable their exclusion from preparing foods based on the Food Code.[6,7] However, most restaurant businesses that operate across the United States do not actually follow these recommendations until they experience/cause a norovirus outbreak. The evidence for this is clear, as these viral foodborne diseases continue to cause the most illnesses and outbreaks due to working sick employees.[8] The difficulty in correctly screening an employee for an illness, correctly deciding exclusion, and then managing that employee’s return to work can be a challenge and now even more so due to COVID-19 screening needs. Nevertheless, this works when performed properly. When combined with other controls (see below), the U.S. Centers for Disease Control and Prevention (CDC) has recommended a decision tree for protecting the public health in restaurants as they start to reopen dining areas.[9]
Foodborne-Illness Screening
The first transmission event (and the most effective control of it) starts with identifying the employee who may be sick via the signs and symptoms of a foodborne illness. For the wellness check to be effective, the foodservice business should train employees about when to report that they have these signs and symptoms and/or have received a diagnosis of any of these symptoms before they come to work. It is best to establish this training via a health policy that the employees can agree to before they begin work; it’s equally important to perform a wellness check at the beginning of every shift (perhaps when an employee clocks in). An example SOP can include:
a. Ask each employee at the time of the assessment if they have any of these symptoms:
i. Diarrhea; may also be a symptom of COVID-19
ii. Vomiting in the past 24 hours; may also be a symptom of COVID-19
iii. Fever and/or sore throat; note that fever or an employee feeling feverish is also a possible symptom of COVID-19
iv. Jaundice (yellowing of the skin or eyes)
v. Open wounds on hands/arms from cuts or burns with fever
b. Ask employees if they have been to the doctor and have received a diagnosis of any of these illnesses or pathogens:
i. Norovirus
ii. Hepatitis A
iii. Shigella spp.
iv. Shiga toxin-producing Escherichia coli
v. Typhoid fever (caused by Salmonella Typhi)
vi. Salmonella (nontyphoidal)
c. If any employee has these symptoms or has received a diagnosis of these infectious diseases or pathogens, they should be excluded from work and placed on the sick log; the only exception to this recommendation is when an employee has open wounds on hands or arms, these wounds are not releasing any body fluids, and it is feasible for the wounds to be covered with medical bandaging; in such cases, it is best that the employee be restricted from preparing and serving foods until the wounds are healed.
d. Check to ensure no employee who has been excluded from work is actually working during the shift by consulting the sick log to ensure that the sick employee does not return to work before allowed.
It is important to use a sick log (Figure 1) to track all employee exclusions, including the employee’s name and the date they are excluded from work, due to the signs and symptoms of foodborne illnesses and COVID-19. It is also then important to establish the policy to determine when an excluded employee may return to work.[10] A sick log can also help ensure an excluded employee is not placed on the work schedule until they have met the criteria to return to work and are removed from the log. This is even more important now due to COVID-19 and the resultant federal and state rules, many of which may be enforced by state and local health departments.
Returning to Work after Foodborne Illness
Allowing employees to return to work after exclusion with a possible or diagnosed foodborne illness depends on several factors. Each of the most common foodborne pathogens has unique characteristics of illness in humans. How long pathogens are shed in the stool and vomit affects when a food employee can return to work. Considerations for the manager include: Was the employee asymptomatic? Is medical documentation required? And is a regulatory authority approval required before they are allowed to return to work? The following recommendations are based on best practices and aligned to the most current Food Code.[7]
Signs and Symptoms
Vomiting: may return to work after 24 hours with no symptoms and was not diagnosed with a foodborne illness.
Diarrhea: may return to work after 72 hours with no symptoms and was not diagnosed with a foodborne illness. Any employee with chronic diarrhea must have medical documentation that the employee is not infectious before returning to work, as diarrhea may also be a symptom of COVID-19.
Jaundice: may return to work only after receiving medical documentation and regulatory authority approval that the employee is no longer infectious.
Fever and/or sore throat: may return to work if no other symptoms and no fever without the use of fever-reducing medications for 24 hours. Note that fever or an employee’s feeling feverish is also a possible symptom of COVID-19, so ensure that you carefully consider COVID-19 return-to-work criteria as well.
Diagnoses
Norovirus: may return to work only after no symptoms for 72 hours and upon receiving medical documentation and regulatory authority approval that the employee is no longer infectious.
Shigella: may return to work only after no symptoms for 7 days or upon receiving medical documentation and regulatory authority approval that the employee is no longer infectious.
Salmonella Typhi: may return to work only after no symptoms for 14 days or upon receiving medical documentation and regulatory authority approval that the employee is no longer infectious.
E. coli O157:H7: may return to work only after no symptoms for 7 days or upon receiving medical documentation and regulatory authority approval that the employee is no longer infectious.
Hepatitis A: may return to work only after receiving medical documentation and regulatory authority approval that the employee is no longer infectious.
Note: See the most current Food Code for recommendations on additional history of exposure and past-illness return to work, and use FDA’s Retail Food Protection: Employee and Personal Hygiene Handbook[11] as a reference to develop your employee health policy. You should also monitor these FDA resources for updates on foodborne illnesses transmitted through food, including FDA-recommended exclusion and restriction-from-work recommendations.