School Meal Program
Few Instances of Foodborne Outbreaks Reported, but Opportunities Exist to Enhance Outbreak Data and Food Safety Practices Gao ID: GAO-03-530 May 9, 2003More than 28 million children receive meals daily through the federal school meal programs. Providing meals that are safe is especially important because young children have a higher risk of complications from some foodborne illnesses. GAO examined (1) the frequency and causes of reported foodborne illness outbreaks associated with the federal school meal programs and (2) the practices that federal, state, and local governments as well as other food providers find useful for safeguarding meals.
GAO found that 195, or about 3 percent, of the total of 7,390 foodborne outbreaks that were reported nationwide, between 1990 and 1999, occurred in schools. Specific national data on whether these outbreaks were related to the federal school meal programs do not exist; however, GAO's survey of state health officials provided information on 40 large outbreaks involving these programs. Nearly half of these large outbreaks resulted from improper food preparation and handling practices in school kitchens. Most commonly, foods involved in the outbreaks were contaminated with Norwalk-like viruses, which cause a mild gastrointestinal illness. However, data limitations make comprehensive assessment of the safety of school meal programs difficult. In particular, the reporting mechanism that states use to voluntarily report outbreaks to the Centers for Disease Control and Prevention (CDC) does not distinguish between outbreaks in schools involving the school meal programs and those involving food from other sources, such as brought from students' homes. Federal, state, and local governments, as well as other food providers use a variety of practices to safeguard meals. Some of them may have national applicability to the federal school meal programs. For example, having key food service personnel trained and certified in food safety would address the improper food preparation and handling practices that caused most of the outbreaks reported in GAO's survey. Purchasing precooked or irradiated meat and poultry products could reduce the risk of foodborne illness in schools. Furthermore, the U.S. Department of Agriculture requires that some of the commodities it donates to schools be purchased under more stringent safety standards than the agency's regulatory requirements for meat and poultry processors. Currently, these more stringent procurement requirements are not readily accessible for school districts' use. While the practicality of applying these food preparation/handling and purchasing practices to the nation's schools has not been assessed, several food safety experts believe that applying these practices in all schools would enhance the safety of federal school meals. Some of these practices would likely lead to increased food costs for schools.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-03-530, School Meal Program: Few Instances of Foodborne Outbreaks Reported, but Opportunities Exist to Enhance Outbreak Data and Food Safety Practices
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Report to Congressional Requesters:
United States General Accounting Office:
GAO:
May 2003:
SCHOOL MEAL PROGRAMS:
Few Instances of Foodborne Outbreaks Reported, but Opportunities Exist
to Enhance Outbreak Data and Food Safety Practices:
GAO-03-530:
GAO Highlights:
Highlights of GAO-03-530, a report to Congressional Requesters
Why GAO Did This Study:
More than 28 million children receive meals daily through the federal
school meal programs. Providing meals that are safe is especially
important because young children have a higher risk of complications
from some foodborne illnesses. GAO examined (1) the frequency and
causes of reported foodborne illness outbreaks associated with the
federal school meal programs and (2) the practices that federal,
state, and local governments as well as other food providers find
useful for safeguarding meals.
What GAO Found:
GAO found that 195, or about 3 percent, of the total of 7,390
foodborne outbreaks that were reported nationwide, between 1990 and
1999, occurred in schools. Specific national data on whether these
outbreaks were related to the federal school meal programs do not
exist; however, GAO‘s survey of state health officials provided
information on 40 large outbreaks involving these programs. Nearly
half of these large outbreaks resulted from improper food preparation
and handling practices in school kitchens. Most commonly, foods
involved in the outbreaks were contaminated with Norwalk-like viruses,
which cause a mild gastrointestinal illness. However, data limitations
make comprehensive assessment of the safety of school meal programs
difficult. In particular, the reporting mechanism that states use to
voluntarily report outbreaks to the Centers for Disease Control and
Prevention (CDC) does not distinguish between outbreaks in schools
involving the school meal programs and those involving food from other
sources, such as brought from students‘ homes.
Federal, state, and local governments, as well as other food providers use a variety of practices to safeguard meals. Some of them may have national applicability to the federal school meal programs. For example, having key food service personnel trained and certified in food safety would address the improper food preparation and handling practices that caused most of the outbreaks reported in GAO‘s survey. Purchasing precooked or irradiated meat and poultry products could reduce the risk of foodborne illness in schools. Furthermore, the U.S. Department of Agriculture requires that some of the commodities it donates to schools be purchased under more stringent safety standards than the agency‘s regulatory requirements for meat and poultry processors. Currently, these more stringent procurement requirements are not readily accessible for school districts‘ use. While the practicality of applying these food preparation/handling and purchasing practices to the nation‘s schools has not been assessed, several food safety experts believe that applying these practices in all schools would enhance the safety of federal school meals. Some of these practices would likely lead to increased food costs for schools.
what GAO Recommends:
GAO recommends that the Secretary of Health and Human Services direct
the Director of CDC to modify the Centers‘ foodborne outbreak
reporting mechanism to add federal school meals as an outbreak
category.
GAO also recommends that the Secretary of Agriculture direct
(1) the Administrator of the Agricultural Marketing Service (AMS) to
highlight its more stringent school-related procurement specifications
on the agency‘s Web page and
(2) the Administrators of AMS and the Food and Nutrition Service to
further promote training and certification of key food service
personnel and study the advantages and disadvantages of donating
precooked or irradiated foods.
USDA and HHS agreed with this report‘s recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-03-530.
To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Lawrence J. Dyckman at (202) 512-3841 or
dyckmanl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
School Meals Caused the Majority of Foodborne Outbreaks in Our Survey
of School Foodborne Outbreaks:
Selected Government and Private Practices Could Enhance Overall Food
Safety in Schools:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: State Health Departments' Survey Results:
Appendix III: GAO's Analysis of CDC Data:
Appendix IV: Food Safety and Security Practices for School Meal Programs
Used or Suggested by Government or
Private Sector:
Appendix V: Comments from the Department of Health and
Human Services:
Appendix VI: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Tables:
Table 1: Number of Reported Foodborne Outbreaks and Related Illnesses,
Hospitalizations, and Deaths, 1973-1999:
Table 2: Number of Reported Foodborne Outbreaks Resulting from Foods
Prepared in Restaurants, Private Homes, Schools, and in Other
Locations, 1973-1999:
Table 3: Number of Illnesses Associated with Reported Foodborne
Outbreaks Resulting from Foods Prepared in Restaurants, Private Homes,
Schools, and in Other Locations, 1973-1999:
Table 4: Number of Illnesses Associated with Reported Foodborne
Outbreaks Resulting from Foods Prepared in Restaurants, Private Homes,
Schools, and in Other Locations, by State, 1973-1999:
Table 5: Reported Foodborne Outbreaks Per 100,000 Population, by State,
1973-1999:
Table 6: Number of Reported Foodborne Outbreaks in Five States
Reporting the Largest Numbers, 1973-1999:
Table 7: Food Safety and Security Practices for School Meal Programs
Used or Suggested by Government or Private Sector:
Figures:
Figure 1: GAO Analysis of CDC Outbreak Data and GAO Survey Responses on
Large School Outbreaks Associated with the Federal School Meal
Programs, 1990-1999:
Figure 2: Total Number of Reported Outbreaks, 1973-1999:
Figure 3: Total Number of Illness Associated with Reported Outbreaks,
1973-1999:
Figure 4: Number of Reported Outbreaks, by Where Food Was Prepared,
1973-1999:
Figure 5: Number of Outbreaks in States Reporting the Largest Number of
Outbreaks, 1973-1999:
Abbreviations:
AMS: Agricultural Marketing Service
ASFSA: American School Food Service Association CDCCenters for Disease
Control and Prevention
FDA: Food and Drug Administration
FNS: Food and Nutrition Service
FSIS: Food Safety and Inspection Service
HACCP: Hazard Analysis and Critical Control Point
HHS: Department of Health and Human Services
USDA: United States Department of Agriculture:
United States General Accounting Office:
Washington, DC 20548:
May 9, 2003:
The Honorable Tom Harkin
Ranking Minority Member
Committee on Agriculture, Nutrition, and Forestry:
The Honorable Richard G. Lugar
United States Senate:
More than 28 million children receive meals daily in almost all of the
nation's public schools, and in many private schools, through the
federally funded National School Lunch Program and School Breakfast
Program. The principal goals of these programs--which cost the federal
government an estimated $8 billion in fiscal year 2002--are to provide
low cost or free meals to children and to help support the agricultural
economy. These meals are generally safe, but our analysis of data from
the Centers for Disease Control and Prevention (CDC) shows that 195
outbreaks of foodborne illness were reported in schools between 1990
and 1999. These outbreaks involved about 12,000 individuals.[Footnote
1] Food safety in schools is especially important because children have
a higher risk of complications from some foodborne illnesses. For
example, children are particularly susceptible to Escherichia coli (E.
coli) O157:H7, a dangerous bacterium that has been found in undercooked
meat and other foods and which can lead to kidney failure and
death.[Footnote 2] According to CDC, children between the ages of 1 and
9 have the highest infection rate for E. coli of all age groups. School
food safety is also important because outbreaks involving school
children have a greater number of illnesses on average. According to
our analysis of CDC data, while school foodborne outbreaks from all
schools constituted less than 4 percent of total U.S. foodborne
outbreaks reported to CDC from 1973 through 1999, they were responsible
for about
10 percent of all outbreak-related illnesses during this period. In
fact, a single outbreak can involve many children. For example, in
1998,
1,700 individuals were sickened by burritos served by school cafeterias
in several states.
The U.S. Department of Agriculture's (USDA) Food and Nutrition Service
(FNS) administers the school meal programs at the federal level. At the
state level, state education agencies typically administer and monitor
the programs through agreements with local school districts' food
authorities. FNS provides about 17 percent of the dollar value of food
served at schools by donating commodities such as meats, poultry, dairy
products, fruits, and vegetables. A key aspect of the programs is the
removal of surplus commodities from the marketplace. Local school food
authorities commercially purchase about 83 percent of the food served
in the lunch and breakfast programs using federal per-meal cash
reimbursements and, to a lesser extent, their own funds.
To prepare for the reauthorization of the Richard B. Russell National
School Lunch Act and to improve the safety of school meals, you asked
us to (1) determine the frequency and causes of reported foodborne
illness outbreaks associated with the federal school meal programs and
(2) identify practices that federal, state, and local governments as
well as other food providers find useful for safeguarding meals from
unintentional and deliberate contamination.[Footnote 3]
To respond to your first concern, we analyzed CDC's foodborne outbreak
database. CDC asks states to voluntarily report outbreaks of foodborne
illness, but they are not asked to provide information on the frequency
and causes of foodborne outbreaks specifically associated with the
federal school meal programs. As a result, the database does not
distinguish between illnesses caused by meals provided through the
federal school meal programs and other sources, such as food brought
from home. Consequently, we conducted a Web-based survey of state
health officials that reported school outbreaks involving 50 or more
individuals between 1990 and 1999 to determine which of these outbreaks
involved federal school meals.[Footnote 4] We also asked these survey
respondents and other state health officials not included in our survey
their opinions on how to enhance CDC's outbreak reporting mechanism. To
respond to your second concern, we contacted food safety experts,
including FNS federal school meals officials and officials from the
American School Food Service Association (ASFSA)--the national school
food service worker professional association, to identify school
districts that are known to have useful food safety practices or are
facing food safety challenges. In addition, we discussed useful food
safety practices with state and local education and health officials.
We also contacted private sector and other food providers regarding
their useful food safety practices. Further details on our scope and
methodology are discussed in appendix I.
Results in Brief:
Our analysis of CDC data shows that 195 foodborne outbreaks in U.S.
schools were reported from 1990 through 1999--representing about
3 percent of the 7,390 reported outbreaks during that period.
Information provided to us by state health officials on 59 large
outbreaks (involving
50 or more people) at schools shows that 40 were associated with meals
served through the federal school meal programs. These outbreaks
affected about 5,500 individuals. The remaining 19 outbreaks were
caused by foods from other sources, such as students' homes. Nineteen
of the
40 outbreaks related to the school meal programs resulted from improper
food preparation and handling practices within the schools, while
8 outbreaks were due to foods contaminated before delivery to the
schools, or to a combination of poor school preparation/handling
practices and before-school contamination. It is not known where the
food involved in the remaining 13 outbreaks was contaminated. In terms
of the agents that caused the foodborne disease involved in these 40
outbreaks, we found that Norwalk-like viruses, which cause a mild
gastrointestinal illness, were the most frequently reported agent. It
is important to note that several data limitations make routine,
accurate, and comprehensive assessments of federal school meal safety
very difficult. As CDC points out, all foodborne illnesses, including
those associated with federal school meals, are underreported.
Moreover, the reporting mechanism that states use to voluntarily report
outbreak data to CDC does not ask states to distinguish between
outbreaks that are caused by foods provided through school meal
programs and those involving foods from other sources. Food safety
experts told us that one possible way of improving CDC's data would be
to revise the reporting mechanism by adding a specific category for
federal school meals. This could yield somewhat better data on the
frequency and causes of reported foodborne illness associated with the
federal school meal programs and help both FNS and state and local
officials determine if additional actions are needed to reduce
foodborne illness in schools. Forty-six health department officials we
contacted in the 50 states and the District of Columbia concurred and
said they could provide this additional information with minimal
difficulty if asked to do so. Five health officials said that they
could not provide this information.
Federal, state, and local governments, as well as other food providers,
use a variety of practices that they consider useful to safeguard
meals. These providers as well as other food safety experts told us
that four of these practices have the potential to enhance the safety
of the federal school meal programs. These practices offer the added
benefit of helping to safeguard school meals from deliberate
contamination. The four practices are (1) employing key food service
personnel who are trained and certified in food safety practices, (2)
implementing a risk-based approach for safely preparing, storing, and
serving foods (such a system should identify potential hazards and
establish controls to mitigate or reduce their occurrence), (3)
purchasing precooked or irradiated meat and poultry products, and (4)
applying the more stringent purchasing specifications that USDA uses
when purchasing some of the food commodities it donates to schools.
Specifically, USDA's procurement specifications require that these
commodities be processed under safety conditions that exceed federal
regulatory requirements for processing of meat, poultry, and other food
products. Currently, these specifications are not easily found because
USDA lists them in procurement documents undifferentiated from standard
federal food safety requirements. The practicality of applying one, or
some combination, of these four practices to the nation's schools has
not been assessed. While experts believe that requiring these practices
would enhance safety, mandating that school districts require training,
a risk-based safety approach, and stringent procurement requirements
would likely necessitate legislative changes at the federal level and
lead to increased food costs for schools. Similarly, if USDA donated
only precooked or irradiated products, food costs would likely
increase.
To improve data on outbreaks that are directly associated with federal
school meals, we recommend that CDC modify the reporting mechanism that
states use to voluntarily report foodborne outbreaks. In addition, to
enhance the safety of school meals, we recommend that USDA make its
stringent purchasing specifications more readily accessible. We also
recommend that USDA further promote the training and certification of
key school food service personnel in food safety practices. Finally, we
recommend that USDA study the advantages and disadvantages of donating
only precooked or irradiated meat and poultry. Since, as we recently
reported, school meal programs' revenues in selected states have not
kept pace with expenses, we stress that such a study should take added
costs into consideration.
We provided HHS and USDA with a draft of this report for their review
and comment. We received written comments from HHS and oral comments
from USDA on the report's contents and recommendations. Both agencies
agreed with the report's recommendations and provided technical
comments, which we have incorporated as appropriate.
Background:
USDA's Agricultural Marketing Service (AMS) and Farm Service Agency are
responsible for procuring USDA-donated foods used to prepare meals for
the National School Lunch Program and the School Breakfast
Program.[Footnote 5] AMS purchases meat, egg products, poultry, fish,
nuts, and fruits and vegetables for donation; Farm Service purchases
grains, oils, peanut products, dairy products, and other foods. USDA
contracts for the purchase of these products with manufacturers that it
selects through a competitive bidding process. FNS, through its Food
Distribution Division, administers the program and donates foods to
state agencies for distribution to schools to meet a portion of
schools' needs. Schools then purchase the remainder of food for school
meals using their own procurement procedures, either purchasing foods
directly from manufacturers or distributors or contracting with food
service management companies that procure the foods for them.
USDA and the Food and Drug Administration (FDA) have ongoing
responsibility for ensuring the safety of the nation's food supply.
USDA regulates meat, poultry, and egg products, while FDA regulates all
other foods. Within USDA, FNS provides food safety guidance to schools
and state agencies that emphasizes proper food handling and personal
hygiene. For example, FNS provides schools manuals that address
appropriate temperatures for reheating ready-to-eat foods and for
maintaining foods at appropriate temperatures to avoid hazardous
contamination. Similarly, FNS provides information on employee personal
hygiene and how it relates to cross-contamination of foods. FNS also
provides schools posters and other food safety-related materials.
As we have reported, CDC monitors foodborne diseases through a variety
of systems. The one most relevant to this review is the Foodborne
Disease Outbreak Surveillance System, created in 1973 to collect data
about cases of foodborne disease contracted by two or more individuals
as a result of ingesting a common food.[Footnote 6] The system covers
all 50 states, the District of Columbia, Guam, Puerto Rico, and the
U.S. Virgin Islands and all types of pathogens, including bacteria,
chemicals, parasites, and viruses. In the event of a foodborne
outbreak, state and local public health department officials can
voluntarily provide data to the system about the pathogen that caused
the outbreak, if known; the contaminated food that was involved; and
factors that contributed to the outbreak. These officials submit this
information to CDC using a paper form or its electronic counterpart.
Analysis of the data shows whether outbreaks occur seasonally and
whether certain foods are more likely than others to contain pathogens.
The data help focus public health actions intended to reduce illnesses
and deaths caused by foodborne disease outbreaks. The data also helps
public health officials identify critical control points in the path
from farm to table that can be monitored to reduce food contamination.
However, the data from this system do not always identify the pathogen
responsible for a given outbreak; such identification may be hampered
by delayed or incomplete laboratory investigation, inadequate
laboratory capacity, or inability to recognize a particular pathogen as
a cause of foodborne disease. In addition, according to CDC officials,
the outbreak surveillance system does not distinguish whether the
source of a school foodborne outbreak was from the federal school meal
programs or other sources such as food brought from home.
Foodborne outbreaks that have recently occurred in schools include the
following:
* From October 1997 through October 1998, 16 outbreaks of foodborne
illness associated with eating burritos occurred in 7 states. All but
one of these outbreaks occurred in schools, and most of the
approximately
1,700 victims were children. Children involved in this outbreak became
ill shortly after consuming the burritos. The cause of the outbreak was
never determined.
* In March 1997, an outbreak of hepatitis A caused by contaminated
strawberries donated by USDA sickened more than 200 teachers and
students in Michigan and about 50 people in other states.[Footnote 7]
Thousands of other students in the affected states received gamma
globulin injections as a preventive measure after being exposed to the
contaminated strawberries.
* In October 1998, 11 children were infected by E. coli O157:H7 in
school lunch taco meat in Finley, Washington. Three of these children
developed hemolytic uremic syndrome, a potentially fatal disease that
can result in anemia and kidney failure. A jury found that the school
district was at fault and awarded $4.75 million to the affected
children, including at least
$3.8 million for one child who is expected to need multiple kidney
transplants in her lifetime. This award is currently being appealed.
School Meals Caused the Majority of Foodborne Outbreaks in Our Survey
of School Foodborne Outbreaks:
Nationwide data on the frequency and causes of foodborne outbreaks
associated with the federal school meal programs do not exist. But,
according to our survey of state health officials, about two-thirds of
the foodborne outbreaks involving 50 or more individuals that occurred
in schools from 1990 through 1999 were caused by meals served through
the federal school meal programs. In addition, our survey shows that
nearly half of those outbreaks resulted from improper food preparation
and handling practices within schools, such as improper food storage
and poor food service worker hygiene. Recent studies conducted by CDC
and FDA are generally consistent with our findings. However, the CDC
study and our analysis point out that significant data limitations make
it difficult to assess the overall safety of school meals nationwide.
In particular, CDC's national database on foodborne outbreaks does not
currently contain sufficiently detailed information on federal school
meal-related outbreaks.
Our Survey of State Health Officials Shows That about Two-Thirds of the
Outbreaks We Examined Involved Foods Served through the School Meal
Programs:
Our analysis of CDC data shows that 195 foodborne outbreaks were
reported in schools from 1990 through 1999. To obtain more information
on federal school meal-related outbreaks than is currently available
from CDC's database, we obtained data from health officials regarding
59 large school outbreaks that occurred in 25 states. Large outbreaks
are those that involve 50 or more individuals. State health departments
are typically involved in the initial investigation and subsequent
reporting to CDC of foodborne outbreaks and are, therefore, able to
provide more detailed information. Specifically, we asked state health
officials whether foods served through the federal school meal
programs, as opposed to foods brought into schools from home or other
sources, were the cause of
59 large outbreaks that occurred in school buildings between 1990 and
1999.[Footnote 8] The state health officials reported that, according
to their outbreak investigations, the federal school meals caused two-
thirds of the outbreaks (40 of the 59). Other foods eaten at schools,
such as foods brought from home or foods served at special events
(i.e., fundraisers) caused the other 19 outbreaks. Figure 1 shows the
number of outbreaks that occurred in schools and the number of
individuals who became ill after consuming breakfast and/or lunch
provided through the federal school meal programs. Although our results
cannot be generalized beyond the 59 large outbreaks included in our
survey, they provide an indication of the frequency and causes of
foodborne illness associated with the federal school meal programs.
Figure 1: GAO Analysis of CDC Outbreak Data and GAO Survey Responses on
Large School Outbreaks Associated with the Federal School Meal
Programs,
1990-1999:
[See PDF for image]
Note: These data represent updated information provided by CDC since
our report: U.S. General Accounting Office, Food Safety: Continued
Vigilance Needed to Ensure Safety of School Meals, GAO-02-669T
(Washington, D.C.: Apr. 30, 2002).
[End of figure]
In addition to asking whether the reported outbreaks involved meals
provided through the federally funded school meal programs, we asked
state health officials about factors that may have contributed to the
outbreaks. The officials reported that 19 of the 40 outbreaks
associated with school meals resulted from poor food preparation and
handling practices within school kitchens. These poor practices include
inadequate cooking, improper food storage and handling, poor food
worker hygiene, sick workers preparing food, and improper hot holding
and cooling of foods. Specifically, improper food storage and poor food
service worker hygiene were each reported in more than half of the 19
outbreaks caused by poor food preparation and handling practices.
Improper holding temperatures for hot foods, improper food handling,
and improper cooling of foods were other frequently reported problems
that contributed to the outbreaks. Only 6 of the 40 outbreaks were
caused by foods that were contaminated before delivery to the school:
for example, strawberries contaminated with Hepatitis A and prepared
burritos contaminated with a still unidentified substance. In 2
outbreaks, state health officials told us that food contaminated before
delivery and poor food preparation practices within the school kitchen
both contributed to the outbreaks. The cause of the remaining 13
outbreaks attributed to federal school meals has not been determined.
Our survey also asked state health officials about the types of
illnesses associated with federal school meal outbreaks. In 8 of the 40
outbreaks that the health officials attributed to the school meal
programs, the agent that caused foodborne illness was never identified.
However, of those that were identified, Norwalk-like viruses were the
most frequently reported cause of illness, associated with 8 of the 40
outbreaks. Norwalk-like viruses cause a mild gastrointestinal illness
that lasts for 24 to 60 hours and that can be transmitted through food
or water contaminated by humans or from one infected person to another.
Staphylococcus aureus, the second most common cause of illness, was
reported in 7 of the
40 outbreaks. It commonly results in diarrhea and vomiting that start
suddenly within 1 to 6 hours of eating a contaminated food. Patients
generally recover within 2 days. Salmonella and Clostridium perfringens
were reported in 5 and 4 of the 40 outbreaks, respectively. Salmonella
causes a gastrointestinal illness and can lead to other serious health
problems, including arthritic symptoms and blood poisoning. Clostridium
perfringens causes intense cramps and diarrhea. Illness is usually over
within 24 hours, but some symptoms may persist for 1 to 2 weeks. The
remaining 8 of the outbreaks involved other disease-causing agents,
including Shigella, hepatitis A, and Bacillus cereus.[Footnote 9]
Appendix II provides further information about our survey to state
health department officials.
CDC and FDA Studies Are Generally Consistent with Our Findings
Regarding the Causes of These Outbreaks:
CDC recently reported on outbreaks that occurred in schools between
1973 and 1997.[Footnote 10] That report was not specific to federal
school meal outbreaks; moreover, it included colleges and universities.
Although CDC's findings are generally consistent with those of our
survey, CDC reported that the cause of illness in 60 percent of the
outbreaks was unknown. In addition, CDC reported that Salmonella was
the most frequent cause of illness (36 percent of outbreaks with a
known cause of illness) while Staphylococcus aureus and Clostridium
perfringens were the second and third most frequently reported causes
of illness.[Footnote 11] CDC also reported that improper storage and
holding temperatures and likely contamination by a food handler were
the most commonly reported food preparation problems. As compared with
our survey results, CDC reported that Norwalk viruses were the cause of
illness in relatively fewer outbreaks, perhaps because tests for
Norwalk-like viruses were unavailable for much of the time period
covered in the CDC report, 1973 through 1997. In fact, in another
recent CDC-sponsored study, CDC researchers suggested that Norwalk-like
viruses are the likely cause of many outbreaks reported to CDC with
unknown causes.[Footnote 12] Our survey also identified fewer outbreaks
of unknown cause than the CDC school foodborne illness study because
our survey focused only on large outbreaks, which are more likely to be
thoroughly investigated. Lastly, the CDC school illness study also
points out limitations in the foodborne outbreak surveillance data,
including underreporting of outbreaks.
In 2000, FDA reported on the occurrence of foodborne illness risk
factors in food service facilities, including elementary
schools.[Footnote 13] FDA designed the study to provide a national
baseline on the prevalence of different risk factors for foodborne
illness. Specifically, investigators evaluated compliance with the 1997
FDA Food Code to determine the presence of risk factors.[Footnote 14]
Risk factors investigated fell into five categories: food from unsafe
sources, inadequate cooking, improper holding temperatures,
contaminated equipment, and poor personal hygiene. This study was also
generally consistent with the results of our survey. The study found
that the food safety risk factors most frequently found in elementary
schools were improper handwashing by food service workers (47 percent
of observations were out of compliance), improper holding temperatures
of cold potentially hazardous foods (45 percent of observations were
out of compliance), and bare-hand contact with ready-to-eat foods (34
percent of observations were out of compliance).
The food preparation risk factors FDA found in elementary schools are
very similar to the most frequent causes of outbreaks in schools that
CDC reported and that we found through our survey of state health
officials. Even though FDA's study focused on risk factors and not on
actual outbreaks, all three studies found that holding temperatures and
contamination by food handlers are key risk factors for foodborne
illness. In particular, the FDA study demonstrates that food
preparation deficiencies are underlying risk factors in all elementary
schools and are not limited to elementary schools where outbreaks have
occurred. All three studies demonstrate the importance of food safety
training for school food service personnel in reducing school foodborne
illness.
Available Data Limit Nationwide Assessment of the Frequency and Causes
of Illnesses Associated with Federal School Meals:
Several important data limitations make routine, accurate, and
comprehensive assessment of food safety in the school meal programs
very difficult. First, as CDC acknowledges, only a small percentage of
all foodborne illness outbreaks are reported by state health officials.
These health officials voluntarily report foodborne outbreaks to CDC
using a paper or electronic form. Data from both of these forms are
combined in the Foodborne Disease Outbreak Surveillance System. A key
reason for underreported foodborne illnesses is that few people
actually seek treatment. In addition, when people do seek treatment,
few illnesses are properly diagnosed, confirmed through laboratory
analysis, and then reported to the CDC surveillance system.
The substantial variability in reporting practices among states is a
second data-limitation factor. Because CDC does not have statutory
authority to require states to report foodborne outbreaks or any other
diseases, states report on a voluntary basis. CDC officials told us
that some states are more proactive than others in reporting foodborne
outbreaks. In fact, our analysis of state outbreak reporting trends
shows a wide variance in reporting practices across states. For
example, from 1973 through 1999, reported outbreaks per 100,000 people
ranged from 66 in Hawaii to 1 in Mississippi. Although CDC guidance
defines a foodborne illness outbreak as two or more cases of a similar
illness resulting from the ingestion of a common food, in practice,
many states investigate and, hence, report only larger outbreaks often
because of limited resources. Appendix III provides further information
about CDC's outbreak data and the variations in reporting across
states.
A third data-limitation factor is that the forms states use to
voluntarily report outbreaks to CDC do not distinguish outbreaks
associated with the school meal programs from other outbreaks that
occur in a school setting. For example, a well-known 1997 outbreak
caused by hepatitis
A-contaminated strawberries is identified in CDC's database as having
occurred in a school, but could not be attributed to the federal school
meal programs. FNS and others acknowledge that the strawberries were
served through the school lunch program.
To address this third limitation, we contacted state health officials
in all
50 states and the District of Columbia to assess the practicality of
adding the choice of "federal school meal" to the foodborne illness
outbreak reporting form that states use to report outbreaks. Forty-six
of the
51 health officials said either that they have the information needed
to specify which outbreaks are due to the federal school meal programs
or that they could obtain this information if they knew it was needed.
Five health officials said that they could not provide this
information. Finally, several health officials we contacted told us
they were uncertain about the definition of a federal school meal.
Consequently, any change to the CDC reporting form would need to
include a precise definition of "federal school meal" for health
officials to use. CDC defines any terms that might be unclear on the
instructions that accompany the form. CDC officials have said that
modifying the form has merit and would not be difficult, and they are
amenable to such a change. Furthermore, several food safety experts we
contacted said that making this change would yield somewhat better data
on foodborne illnesses associated with the federal school meal
programs. USDA's Food Safety and Inspection Service (FSIS) officials
noted that this change might intensify investigative efforts to
establish the food vehicle, the causative agent, and the likely point
of contamination so that corrective and preventative measures can be
implemented.[Footnote 15]
Selected Government and Private Practices Could Enhance Overall Food
Safety in Schools:
Federal, state, and local governments, as well as other food providers,
use a variety of practices to safeguard meals. According to several
food safety experts we consulted, four of these practices could be
applied in all participating schools to enhance the safety of the
federal school meal programs. First, many of the school districts we
contacted require training and certifying of food service workers.
Second, several school districts use risk-based food safety procedures.
These two practices could remedy a major cause of foodborne outbreaks
identified in our study; namely, poor food preparation and handling
practices. Third, several school districts purchase precooked meat and
poultry products to help reduce the risk of foodborne pathogens, and
some food safety experts suggest irradiating these products could also
reduce these risks. Fourth, USDA's stricter food procurement
requirements could help improve the safety of school meals. Lastly,
after the events of September 11, 2001, most of the schools we visited
had reviewed existing measures to prevent deliberate contamination of
school meals, but had adopted few additional safeguards regarding food
security. However, some food safety measures we identified during our
review, such as restricting access to food preparation areas, could
also help protect school meals against deliberate contamination.
Training and Certifying School Food Service Workers Enhance Food
Safety:
Nine of the 14 local school districts we contacted required training
and/or certification of school food service workers to help ensure that
foods served in the federal school meal programs are safe to eat. Food
safety certification training addresses topics such as proper
procedures to safely receive, store, prepare, and serve food. Food
safety experts we contacted believe that certification provides a level
of assurance that key personnel are trained in proper food safety
practices.
The practice of also requiring certification of food service managers
is widespread in the food service industry as well as in most of the
schools we visited. Specifically, food service managers were required
to be certified in food safety in 8 of the 14 schools districts we
contacted. Moreover, as of January 2003, 17 states and 70 local
jurisdictions in several additional states required or will require
some form of training certification for food service managers,
according to the National Restaurant Association Education
Foundation.[Footnote 16] This means that nearly
60 percent of the U.S. population will soon consume food prepared by
certified food service managers.
Similarly, several private sector food service providers we contacted,
including Jack in the Box, a national restaurant chain, and Walt Disney
World, also require food safety training and certification. For
instance, a Jack in the Box representative told us that the company
ensures that all its food managers are certified through the National
Restaurant Association's "ServSafe" food-safety training
program.[Footnote 17] Jack in the Box also provides a 1-day modified
"ServSafe" training course for key food service workers. In addition,
Jack in the Box uses only certified trainers for its own training
program and ensures that its workers are trained on critical food
safety points at each restaurant workstation. The company also
communicates the significance of food safety by showing its workers a
video on food safety responsibilities and actual cases of foodborne
illnesses and their impact on children. According to Walt Disney World
representatives, the company requires that all its food establishments
comply with state food safety certification requirements and uses both
"ServSafe" and the National Register of Food Safety Professionals to
train and certify employees. Food safety concepts introduced through
training are reinforced on a daily basis through signs and newsletters
and by providing food safety information on an intranet site.
Furthermore, the Veterans Health Administration, a division of the
Department of Veterans Affairs that serves about 100,000 meals daily,
requires 20 hours of food safety training annually for all food service
workers. The Veterans Health Administration's health care facility
managers also select key food service workers to be "ServSafe"
certified. Lastly, food safety experts and advocacy groups we
contacted, such as the AFSFA, the Conference for Food Protection, the
Center for Science in the Public Interest, and Safe Tables Our Priority
support the concept of mandatory nationwide training and certification
of key food service workers, such as schools' food service managers,
supervisors, or head cooks.[Footnote 18]
Certification courses for food service workers are available from
several sources. Certification courses include that of ASFSA, the
National Environmental Health Association, and others approved by the
Conference for Food Protection, such as courses of the National
Restaurant Association and the National Registry of Food Safety
Professionals. As of February 2003, about 27,000 persons had been
certified by ASFSA. Certification requirements may be fulfilled by
completing the "Serving It Safe" food safety course developed by FNS
and the National Food Service Management Institute.[Footnote 19] In
addition, 1.5 million food service workers have been certified by
National Restaurant Association's "ServSafe" food safety training
program.
While we found broad support for voluntary food safety training of food
service workers, some stakeholders--certain school districts, state and
local education and health agencies, and others--we contacted had mixed
opinions about the need for or practicality of mandating certification
requirements. Supporters believe that a federal certification
requirement is a practical minimum threshold to help ensure safer food
service operations in all school districts. Skeptics expressed concerns
about the benefit of mandatory federal certification because of the
costs and time involved in acquiring certification and monitoring and
standardizing training programs. These concerns may be especially
applicable to rural or small school districts. Officials at one school
district where the health department requires all food service managers
to be certified told us that they were barely able to pay for food
service workers' examination fees, yearly certification costs, and
textbook expenses, especially with the high turnover of food service
employees. In addition, USDA officials say that such a mandate would
necessitate a legislative change because USDA currently lacks such
authority under the Richard B. Russell National School Lunch Act or the
Child Nutrition Act of 1966.
Using Risk-Based Food Safety Procedures Strengthens Schools' Food
Safety Efforts:
Some school food service operations we visited were required by state
or local health authorities to follow food safety procedures based on
the Hazard Analysis and Critical Control Points (HACCP) system. HACCP
is a risk-based system that identifies where contamination is mostly
likely to occur and then establishes controls to prevent or reduce food
contamination.[Footnote 20] The school districts we visited used some
aspects of the HACCP system for preparing, storing, and serving food.
For example, they had easy-to-use HACCP-based inspection checklists,
such as those provided by FNS or others for monitoring food service
operations that enable supervisors to assess the implementation of food
safety procedures, such as frequency of food temperature checks.
FNS supports and encourages voluntary HACCP training for school food
service personnel. For example, FNS provides to schools the National
Food Service Management Institute's "Serving It Safe" course, which is
based on HACCP principles. The course helps food service workers
understand risk-based principles and develop and implement a HACCP
plan. Institute officials told us that, as of September 2002, over
250 individuals from 45 states had attended its Instructor Orientation
to HACCP for Child Nutrition Programs. As a direct result of this
training, these instructors provided local training to nearly 1,700
participants in
20 states. Several school districts, state and local educational and
health agencies, and food safety experts told us that key elements of
HACCP-based systems, such as monitoring food temperatures frequently,
is very important for food safety. Some also said that having easy-to-
use food inspection checklists to record HACCP-based practices should
be required elements of any school food service operation. These
checklists are available from a variety of sources, including FNS's
HACCP-based voluntary guidance for school food safety. FNS also makes
available on-line recipes that include HACCP information.
Private sector food providers we contacted also implement risk-based
food safety approaches to food preparation and handling. For instance,
Walt Disney World told us that it uses a HACCP approach in all its food
service locations, which includes checking and recording the
appropriate temperatures for cooking, hot holding, cold holding,
cooling, and reheating of foods. The company also uses daily and weekly
self-inspection checklists to monitor items such as employee hygiene,
equipment and facility sanitation, food storage, pest control, and
garbage disposal. To prevent or reduce cross-contamination, the company
requires the proper use of gloves and differently colored cutting
boards designated for different types of food. Officials from Sodexho,
a national food service management company, said it uses similar food
safety practices in its HACCP plan. The company employs an independent
audit firm to verify compliance with the plan by conducting unannounced
audits of its facilities. Finally, the Veterans Health Administration
has a nationwide food safety policy that includes a HACCP requirement
in all its facilities. Veterans Health Administration officials told us
that monitoring devices are used to continuously record temperatures of
food storage areas, even during power outages.
Some food safety experts said that mandating HACCP principles to all
participating schools would enhance the safety of federal school meals.
However, some school districts and state and local education and health
agencies expressed reservations about mandating a comprehensive HACCP
system, such as the one adopted by New York City, because of its costs.
New York City's HACCP plan for schools, which is part of a program
mandated by the city's Office of School Food and Nutrition Services, is
240 pages long. It contains detailed guidance, instructions,
checklists, and logs for activities such as monitoring critical control
points. Some school food service managers and others told us that small
and rural school districts would be challenged to implement such an
extensive effort. In addition, some food service managers told us that
some HACCP requirements are complicated and could present a challenge
to food service workers who may have limited educational backgrounds or
who do not speak English as their primary language--common issues among
school food service workers.[Footnote 21] Also, school districts that
do not cook meals from scratch but instead rely on prepackaged meals
would need less extensive risk-based plans for food service workers. As
a result, HACCP requirements would have to be modified to reflect
schools' various food service operations. USDA officials told us that
mandating HACCP in schools would necessitate a legislative change
because USDA currently lacks such authority under the Richard B.
Russell National School Lunch Act or the Child Nutrition Act of 1966.
Lastly, if HACCP-based systems were used, several food safety experts
told us that monitoring and enforcing these systems would be essential
for their full effectiveness.
Using Precooked or Irradiated Meat and Poultry Products Reduces Food
Contamination Risks:
According to some food safety experts, proper precooking or irradiation
would eliminate or reduce potential pathogens from raw meat and poultry
and thus decrease the possibility of foodborne disease outbreaks in
school meals.[Footnote 22] Some school districts, including six we
contacted, use precooked meat or poultry products to a large extent.
This practice is supported by several private sector food service
providers and by food safety experts. Specifically, food safety experts
state that purchasing meat that has been precooked to proper
temperatures is an effective way to minimize the risk of E. coli
O157:H7 and Salmonella, which are frequently found in raw meat, and in
the case of Salmonella, raw poultry. By eliminating the need to cook
raw meat items after they arrive at the school district, schools may
also reduce labor costs and eliminate the need for some equipment. For
example, in February 2001, the Minnesota Department of Children,
Families & Learning's Food and Nutrition Service sent a notice to all
school authorities recommending that all raw meat, whether obtained
from USDA or purchased from commercial sources, be reprocessed into
fully cooked products to minimize the risks associated with E. coli
O157:H7 contamination. This advisory followed an E. coli O157:H7
outbreak in a Minnesota school.
USDA already purchases some precooked meat and poultry products for
donation to schools and other nutrition programs. According to USDA's
most recent study of nationwide school food acquisitions, in terms of
cost, USDA provided more than half of the precooked ground beef and
almost half of the precooked beef patties used at schools during the
1996-97 fiscal year.[Footnote 23] However, USDA does not have similar
information on its purchases of poultry products. Nevertheless, during
fiscal year 2002, AMS purchased 16.4 million pounds of cooked diced
chicken; 5.5 million pounds of cooked cut-up chicken; and 5.3 million
pounds of cooked chicken fajita strips, patties, and nuggets for
donation.
However, USDA officials said that precooking meat and poultry adds to
the cost of those foods and could reduce the overall amount of USDA-
donated commodities provided to local school districts. For example,
raw chicken costs USDA about 50 cents per pound, and precooked chicken
costs USDA about $1.35 per pound. Specifically, USDA officials told us
that requiring USDA to donate only precooked meats or poultry would
decrease the amount of those commodities that USDA could donate by
shifting more funds to pay for the costs of processing rather than the
costs of acquiring raw products. It would also lessen the impact of
USDA's efforts to remove surpluses of those commodities from the
marketplace, one of the goals of the school meal programs. According to
FNS officials, donating only precooked meats or poultry would reduce a
given school district's ability to select the commodities based on
local schools' preferences and specifications. Although there are no
available costs estimates, some experts believe that the additional
expense of precooking certain high-risk foods may be offset by the
savings in health care costs associated with school foodborne
outbreaks.
Another more controversial technique to reduce bacteria in meat and
poultry is irradiation. Proper irradiation of foods would kill 99.9
percent of Campylobacter jejuni and Listeria monocytogenes, as well as
E. coli O157:H7 and Salmonella--foodborne pathogens that are associated
with meat and poultry.[Footnote 24] FDA and USDA have approved
irradiation for reducing pathogens in raw meat and poultry
products,[Footnote 25] and some food safety experts suggest that
irradiation should be used on the meat and poultry products that USDA
donates to the federal school meal programs. In addition, scientific
organizations, including the American Dietetic Association, the
American Medical Association, CDC, and the World Health Organization,
have endorsed food irradiation. Other entities, however, such as the
Consumer Federation of America, the Center for Science in the Public
Interest, the Physicians Committee for Responsible Medicine, and Public
Citizen, oppose serving irradiated foods to children pending more study
on its long-term health effects. In 2000, we reported that scientific
evidence indicates that the benefits of food irradiation outweighed the
risks.[Footnote 26]
USDA is taking actions concerning the possible introduction of
irradiated food into the federal school meal programs, and a decision
of whether to purchase irradiated products is pending. Currently, USDA
does not donate any irradiated meat and poultry products to the federal
school meal programs. According to USDA officials, a provision in the
Farm Security and Rural Investment Act of 2002 directs USDA to allow
any food safety technology approved by USDA or the Department of Health
and Human Services, including irradiation, to be used for commodity
purchase programs, including the federal school meal programs. In
November 2002, USDA requested public comments on implementing this
provision. USDA plans to publish its irradiation policy for commodity
donations later on in 2003. USDA officials noted that costs are
associated with the irradiation process and that irradiated products
available in consumer markets cost more than nonirradiated products.
Therefore, irradiating donated meat and poultry products could add to
the cost of these foods and, without additional program funding, could
reduce the overall amount of USDA-donated commodities provided to local
school districts.
At the local level, federal regulations do not prohibit schools from
serving irradiated foods should they choose to purchase them
commercially. Although we found that irradiated meat and poultry are
available in many parts of the nation for commercial purchase at local
outlets or from food distributors, no schools are known to currently
serve irradiated foods, according to the ASFSA and FNS. Regarding
irradiation, food safety experts believe that certain issues need to be
addressed, including whether the schools would serve irradiated foods,
how related notifications to school children and their parents would be
handled, and the extent to which students would have alternatives to
irradiated food items. In this regard, FNS provided a grant to the
Minnesota Department of Children, Families & Learning for development
of an educational pilot that will include materials for school staff
and parents regarding food safety and the use of irradiated foods as
one option to ensure a safe food supply. USDA is to receive a final
report on the pilot, including prototype educational materials by
September 2003. Also, FNS plans to distribute to state agencies and
school districts publications developed by FDA and FSIS to respond to
common food irradiation questions.
Although precooking and irradiation may be viewed as key approaches to
eliminating foodborne disease, food safety experts and USDA note that
neither practice provides an absolute guarantee against foodborne
disease and stress that proper preparation and handling of irradiated
and precooked meats is still needed. USDA is reviewing the comments it
received in response to a request for public input on these food safety
technologies and has not made a final decision on implementation of the
congressional mandate. Spokespersons for four entities we contacted--
the Conference for Food Protection, the National Food Service
Management Institute, the National Restaurant Association, and
Resources for the Future--and others caution that irradiating and
precooking foods do not protect the food from recontamination through
mishandling by food service workers during meal preparation.
USDA Has Established Contracting Specifications for Enhancing the
Safety of Foods It Donates to Schools:
As we reported in February 2000, USDA has established policies and
procedures to further ensure the safety of foods purchased for donation
to schools.[Footnote 27] In particular, AMS's procurement contracts for
school-donated foods include provisions that specify more stringent
testing than is required by USDA's FSIS and by FDA. According to AMS
officials, AMS developed these provisions because it believes that the
nation's school children warrant food safety-related protections that
are more stringent than those applied to the nation's population in
general.
Under AMS's more stringent procurement specifications, suppliers of
food products that pose microbial contamination concerns--i.e., beef,
poultry, and eggs--are subject to stricter pathogen testing.
Specifically, contracts for diced chicken specify pathogen testing for
every lot because the product is susceptible to contamination. Also,
while FSIS's regulations require that raw ground beef destined for the
general public be subject to a series of random sample testing for
Salmonella,[Footnote 28] with a standard of no more than 7.5 percent of
each sample being positive for Salmonella, AMS contracts require that
all production lots of raw ground beef destined for school donation
receive E. coli O157:H7 and Salmonella testing, both with a zero
tolerance. Finally, AMS's procurement contracts establish specific
temperature requirements during transportation from processing plants
to the final destination. Accordingly, the trucks or railcars used to
transport meat or poultry products and frozen or chilled fruit and
vegetable products must have refrigeration units capable of maintaining
the required temperatures. AMS also requires satisfactory annual plant
surveys for suppliers of processed fruits and vegetables.
These procurement policies and procedures that are to safeguard foods
donated to schools, do not apply to foods purchased by local schools.
Since local schools purchase about 83 percent by value of the food
served through the federal school meal programs, some food safety
experts, such as representatives of the Conference for Food Protection
and Resources for the Future, believe that USDA should require school
districts to purchase foods according to AMS's more stringent
specifications. However, mandating that schools use the stricter
purchasing specifications would necessitate a legislative change
because USDA currently lacks such authority under the Richard B.
Russell National School Lunch Act or the Child Nutrition Act of 1966.
Furthermore, USDA officials say that practical challenges exist for
many schools in implementing its more stringent specifications.
Specifically, food suppliers of small or rural school districts where
there is limited competition for school business, might not bid for
food contracts because of the increased cost associated with meeting
the requirements. As a result, schools might face significantly higher
costs and have access to fewer suppliers. Also, many districts do not
purchase foods directly from processors but rather rely on food
distributors, food brokers, and/or food service management companies to
purchase the foods served in their schools. According to AMS, these
businesses may be reluctant to pay higher wholesale prices for products
meeting specific purchase requirements.
An alternative to mandatory purchasing specifications would be to make
USDA's more stringent requirements more readily accessible to school
districts and allow them to decide whether to use the requirements.
Officials at several school districts we contacted and representatives
from the Consumer Federation of America and Resources for the Future
told us that having these food safety specifications readily available
to schools for their own commercial food purchases would be useful in
promoting food safety. Accessing such information is currently
difficult because AMS lists these specifications in its commodity
procurement documents along with, and undifferentiated from, standard
federal safety requirements. For example, the few paragraphs containing
stricter purchase specifications for microbiological testing are
contained in a 28-page AMS commodity specification for frozen cooked
diced chicken. AMS officials told us that the idea of extracting the
specifications and prominently displaying them on the AMS Web page to
make them more accessible to interested school officials has merit and
would not be burdensome. AMS said that while these specifications are
developed for specific processes and products and may be useful in
helping schools develop their own food purchases specifications, they
should not be applied universally to all situations and products.
As discussed earlier, the practicality of applying USDA's purchasing
practices and other useful practices we identified to all the nation's
schools would depend on the size of the school district, the resources
available to it, and the way each district prepares and serves meals.
In addition, as we have recently reported, for school year 1996-97
through 2000-01 expenses associated with federally funded school meals
in selected states have increased faster than revenues.[Footnote 29]
Nevertheless, some food advocacy organizations, including the Center
for Science in the Public Interest and the Consumer Federation of
America, believe that the absence of minimum national safety
requirements for the federal school meal programs reduces the assurance
that all school districts have basic food safety practices in place.
They believe that creating national requirements for these programs
would enhance the safety of school meals. Furthermore, the Center for
Science in the Public Interest and other food safety experts believe
that four food safety practices in particular--training and
certification of food service workers, using risk-based food safety
procedures, using precooked and irradiated meat and poultry products,
and applying AMS's stricter purchasing specifications--warrant further
study of their national applicability, including the advantages and
disadvantages, such as increased costs. These experts believe that such
a study should address school districts' resource constraints, the
potential impact on the school meal programs' commodity surplus removal
mission, and the need to request any specific legislative
authorization.
Some School Districts Are Reemphasizing Food Security Practices after
the Events of September 11, 2001:
After the events of September 11, 2001, some school district officials
said that they had reviewed their food security procedures for
preventing deliberate contamination of school meals and while they
found them to be adequate, were reemphasizing them. However, beyond
reemphasizing existing procedures to prevent deliberate contamination,
the school districts we contacted had not taken many additional
measures to address food security. Several of the measures implemented
to help ensure food safety, such as tight controls over loading docks
where schools receive food deliveries or restrictions on access to food
preparation areas, are equally important to improving security.
Regarding new security measures, one district official had visited
local food suppliers especially to review their food security practices
to protect products such as bread, juice, and milk from deliberate
contamination. Officials at other school districts that we visited told
us that they routinely visit facilities of new or existing food
suppliers to ensure the safety and security of suppliers' operations.
To strengthen school districts' efforts to prevent deliberate
contamination of school meals, FNS has drafted school-specific food
security guidance, which includes sections on supplier selection and
personnel and operational security. This guidance will supplement more
general voluntary guidance on food security that USDA and FDA have
developed for dissemination to food producers, processors, and
providers.[Footnote 30] The voluntary guidance includes FSIS's 2002
security guidelines for meat, poultry, and egg processors, which
contain sections on security for storing, shipping, and receiving food
products.[Footnote 31] As of March 2003, FNS had not established an
issuance date for its guidance for school districts. We believe that
this guidance is comprehensive and thorough and should facilitate
school districts' efforts to better protect school meals from acts of
deliberate contamination.
A more complete list of the useful school food safety and food security
practices that we identified during our review is contained in appendix
IV.
Conclusions:
School and other government officials currently lack accurate and
comprehensive data on the frequency and causes of foodborne illness
outbreaks associated with the federal school meal programs. A more
accurate picture of the magnitude and causes of foodborne illness
outbreaks in the school meal programs is needed to determine how much
to invest in food safety practices and where to focus resources. Such
information is of particular importance because children have a higher
risk of complications from some foodborne illnesses and because of the
considerable financial investment by American taxpayers in the federal
school meal programs. In addition to obtaining more accurate and
comprehensive data on the frequency and causes of foodborne illness,
options exist to help minimize the occurrence of foodborne outbreaks in
schools at both the local and federal levels. However, the costs
associated with implementing any additional measures should be
carefully considered. As we recently reported, school districts in
selected states experience year-end revenue shortfalls.
Recommendations for Executive Action:
To improve nationwide data on the frequency and causes of foodborne
illness associated with the federal school meal programs, we recommend
that the Secretary of Health and Human Services require the Director of
the Centers for Disease Control and Prevention to revise the reporting
mechanism that states use to voluntarily report foodborne outbreaks.
Specifically, states should be prompted to specify whether reported
outbreaks involved foods served through the federal school meal
programs.
To assist schools in their efforts to purchase safer food, we recommend
that the Secretary of Agriculture direct the Administrator of the
Agricultural Marketing Service to highlight on AMS's Web page the more
stringent product safety specifications USDA uses when purchasing foods
it donates to schools.
To enhance the safety of the federal breakfast and lunch programs in
participating school districts, we recommend that the Secretary of
Agriculture direct the Administrator of the Food and Nutrition Service
to further promote training and certification of key school food
service personnel in food safety practices by, for example, publicizing
the range of food safety training and certification opportunities
available to school food service personnel from ASFSA, the National
Restaurant Association, and other sources.
To reduce the risk of bacterial contamination of food products USDA
donates to schools, we recommend that the Secretary of Agriculture
direct the Administrators of the Food and Nutrition Service and the
Agricultural Marketing Service to study the advantages and
disadvantages, including costs, of USDA donating only precooked or
irradiated meat and poultry products to schools. Depending on the
results of the study, the Secretary should consider whether to adopt
these practices.
Agency Comments and Our Evaluation:
We provided HHS and USDA with a draft of this report for their review
and comment. HHS provided written comments and agreed with our
recommendation. Specifically, HHS said that CDC is amenable to changing
the outbreak reporting mechanism since many state health officials told
us that they are willing to collect and report additional information
on the source of foods implicated in school-related foodborne
outbreaks. HHS's comments are presented in appendix V.
USDA's Deputy Administrator for Special Nutrition Programs provided us
with the agency's oral comments on April 15, 2003. USDA generally
agreed with the report's contents and recommendations. In addition,
USDA officials from the Agricultural Marketing Service, the Food and
Nutrition Service, and the Food Safety and Inspection Service provided
technical comments to enhance the clarity of the report. In particular,
the officials wanted us to ensure that the report is clear regarding
the scope of our survey and that its results cannot be projected. We
have made modifications to address this concern. The officials also
noted that improper food handling and poor worker hygienic practices
are responsible for many outbreaks and that food contaminated prior to
delivery to schools was found in a minority of outbreaks. We concur
with this technical comment. As our report clearly states, the results
of our survey indicate that food handling is a leading cause of
foodborne outbreaks. Finally, the officials commented that irradiating
meat products could add to the cost of these products, depending upon
market conditions and diverse factors. They noted however that
additional program funding, industry subsidies, or other factors could
prevent any such cost increases or decreases in the amount of USDA-
donated commodity. Our report acknowledges that additional costs would
be involved and recommends that USDA study the advantages and
disadvantages, including costs, of donating only precooked or
irradiated meat and poultry products to schools.
We conducted our review from August 2002 through April 2003 in
accordance with generally accepted government auditing standards.
Appendix I contains the details of our scope and methodology.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. We will send copies of this report to
congressional committees with jurisdiction over food safety programs;
the Secretaries of Agriculture and Health and Human Services; the
Director, Office of Management and Budget; and other interested
parties. We will also make copies available to others upon request. In
addition, the report will be made available at no charge on the GAO Web
site at http://www.gao.gov.
If you have any questions about this report, please contact
Maria Cristina Gobin or me at (202) 512-3841. Key contributors to this
report are listed in appendix VI.
Lawrence J. Dyckman
Director, Natural Resources and Environment:
Signed by Lawrence J. Dyckman
[End of section]
Appendix I: Scope and Methodology:
To determine the frequency and causes of foodborne illness associated
with foods served through the federal school meal programs, we surveyed
state health officials using a Web-based survey. We focused on state
health officials because they are typically involved in the initial
investigation and subsequent reporting to the Centers for Disease
Control and Prevention (CDC) of foodborne outbreaks and are, therefore,
able to provide more detailed information. The objectives of our survey
were to determine
(1) whether outbreaks listed by CDC were attributed to the federal
school meal programs and (2) the feasibility of modifying CDC's
Foodborne Disease Outbreak Surveillance System to gather more specific
data about outbreaks associated with the school meal programs.
Regarding the first survey objective, we asked state health officials
in 32 states about
97 outbreaks, each of which, according to CDC's surveillance system,
involved 50 or more individuals and occurred in schools between 1990
and 1999. Of the 97 outbreaks included in the survey, we excluded some
from our analysis for the following reasons: states did not respond to
our inquiries about 3 outbreaks; states responded but lacked sufficient
information to answer questions about 22 outbreaks; and states reported
that, according to their records, 13 outbreaks involved fewer than
50 individuals. The remaining 59 outbreaks in 25 states formed the
basis of our analysis.[Footnote 32] Because the outbreaks included in
the survey are not a representative sample, results of the first part
of the survey cannot be generalized. Regarding the second survey
objective, to determine the views of all states on potential changes to
the CDC reporting system, we also contacted officials in the 19 states
and the District of Columbia that were not included in or did not
respond to the Web survey and asked questions about the modification of
the surveillance system identical to those in the second part of
survey. To obtain perspective on our survey results, we reviewed
relevant CDC studies that addressed the cause of foodborne outbreaks in
schools in general and a FDA study that addressed the risk factors that
contributed to foodborne illness in elementary schools. Lastly, we
discussed with CDC officials and other food safety experts how CDC data
limitations impact food safety assessments of the federal school meal
programs.[Footnote 33] See appendix II for further information about
our survey.
To provide additional information about foodborne illness outbreaks in
general and to put school outbreaks into context, we examined data from
all foodborne illness outbreaks that were reported to the CDC Foodborne
Disease Outbreak Surveillance System from 1973 through 1999. We used
these data to compare the frequency and magnitude of school outbreaks
to those of outbreaks occurring in other locations. We also examined
the variability of reporting practices across states. Our analysis of
CDC data is presented in appendix III.
To identify the types of practices that federal, state, and local
governments and private sector or nonschool meal providers have in
place to protect against contamination of meals, we contacted 14 school
districts, 8 state education or health departments, 4 local health
departments, and 5 private sector or nonschool meal providers regarding
their useful practices in food safety and/or security. We chose the
school districts and other entities in consultation with several school
food safety experts, including the American School Food Service
Association (ASFSA) and federal school meal program officials from each
of the 7 Food and Nutrition Service (FNS) regional offices. Using their
recommendations, we identified and selected school districts with known
useful food safety practices or food safety challenges. In making our
selection, we considered district size, locale (rural, urban, or
suburban), geographic location, and method(s) of meal preparation
(central kitchen, satellite operations, or use of a food service
management company). We conducted on-site reviews of schools' food
safety and security practices at 11 school districts in 7 states--
Illinois, Maryland, New York, Ohio, Rhode Island, Virginia, and
Washington[Footnote 34]--and the District of Columbia. At each
location, we discussed efforts and challenges in food safety practices
with school food authority officials and/or food service site managers.
We discussed state operations and activities with officials in Ohio,
Minnesota, Rhode Island, Washington, and the District of Columbia. To
validate the useful practices and challenges identified from our site
visits, we also spoke with several food safety experts and advocates--
ASFSA, the Center for Science in the Public Interest, the Conference
for Food Protection, the Consumer Federation of America, Kids
First,[Footnote 35] Marler Clark,[Footnote 36] the National Food
Service Management Institute, the National Restaurant Association,
Physicians Committee for Responsible Medicine, Resources for the
Future, and Safe Tables Our Priority.[Footnote 37]
To identify practices that other meal service-providing entities use to
safeguard food that could be applicable to the federal school meal
programs, and to validate the useful practices and challenges
identified from our school site visits, we contacted several private
sector or nonschool meal providers--Chef America, Jack in the Box,
Sodexho,[Footnote 38] the Veterans Health Administration, and Walt
Disney World. We also contacted two healthcare organizations--the
American Dietetic Association and the Joint Commission on Accreditation
of Healthcare Organizations--to learn about policies these
organizations use or suggest to safeguard the health of populations
most vulnerable to foodborne illness. We selected these private sector
or nonschool meal providers and other entities to obtain a wide range
of useful food safety and security
practices, and we discussed with these entities their practices'
potential applicability to the federal school meal programs. However,
we did not independently evaluate these private sector or nonschool
meal provider food safety practices. We also spoke with the private
food safety experts and advocacy groups listed previously to further
identify useful private sector food safety and security practices.
[End of section]
Appendix II: State Health Departments' Survey Results:
To determine the frequency and causes of reported foodborne illness
outbreaks associated with the federal school meal programs, we surveyed
state health officials using a Web-based survey. This survey was
divided into two parts. The objective of the first part of the survey
was to gain additional information about school foodborne illness
outbreaks involving 50 or more individuals between 1990 and 1999. Each
survey addressed a single outbreak; thus, some states completed surveys
for more than one outbreak. Of the 97 outbreaks included in our survey,
38 were excluded from analysis for the reasons described in appendix I.
Results from the remaining 59 outbreaks are summarized herein. Though
these survey results provide information on school foodborne illness
outbreaks that affected 50 or more people, they are not a
representative sample and are not projectable. The objective of the
second part of the survey was to determine the feasibility of modifying
CDC's Foodborne Disease Outbreak Surveillance System to gather more
specific data about outbreaks associated with the federal school meal
programs. For more information about the survey methodology, see
appendix I.
The following summarizes the questions asked and the answers provided
by the relevant state health officials that were able to provide
details for the 59 outbreaks included in the first part of the survey.
According to the survey respondents, 40 of the 59 outbreaks involved
foods served through the federal school meal programs. The 40 school
meal outbreaks described in this report are a subset of these data. The
results of question 1 below have been recoded based on follow-up
contacts with state health officials and our review of the completed
surveys. Therefore, the response categories included for question 1 are
different than those in the original survey.
[See PDF for image]
[End of table]
The following three items describe responses for all 59 outbreaks
involving 50 or more individuals.
[See PDF for image]
[End of table]
[End of section]
Appendix III: GAO's Analysis of CDC Data:
Using data from the CDC's Foodborne Disease Outbreak Surveillance
System, we examined patterns in foodborne illness outbreaks in general
and in school outbreaks in particular. We examined data covering the
time period from 1973 through 1999, the last year for which complete
outbreak data were available at the time of our review. Table 1 shows
the total number of outbreaks, and the numbers of illnesses,
hospitalizations, and deaths associated with them, that were reported
over the entire period. Figure 2 shows the total number of reported
outbreaks, and figure 3 shows the total number of illnesses.
Table 2 shows the number of reported outbreaks that resulted from foods
in restaurants, private homes, schools, and other locations. It is
important to note that this analysis does not identify foods that are
served through the federal school meal programs. Overall, 4 percent of
the outbreaks resulted from foods in schools; 54 percent from food
prepared in restaurants; 15 percent resulted from foods in private
homes; and
23 percent from foods in other locations, including churches, caterers,
grocery stores, nursing homes, and a broad array of other locations.
For about 5 percent of the reported outbreaks, the location was
unknown. The percentage of outbreaks attributable to foods in schools
fluctuated between 2.3 percent and 5 percent across the various 3-year
intervals. As data supporting figure 4 show, the number of school
outbreaks over the entire period follows a trend similar to the trends
in outbreaks resulting from foods in restaurants and in private homes-
-that is, the numbers increased for all three groups of outbreaks
between the early and late 1990s. Outbreaks resulting from foods
prepared in the other locations increased somewhat more linearly over
the entire period.
Interestingly, CDC data show that food outbreaks at schools involve
larger numbers of illnesses than outbreaks that occur in other
locations. Table 3 shows that over the entire period, the 547 reported
outbreaks resulting from foods in schools produced 46,461 reported
illnesses, approximately 10 percent of all illnesses. While each school
outbreak caused 85 illnesses on average, each outbreak associated with
foods from restaurants and private homes caused an average of 18 and 13
illnesses, respectively. Only the category of "other" outbreaks, which
caused an average of 56 illnesses, approached the average number of
illnesses associated with school outbreaks, most likely because many of
the other outbreaks involve institutionalized populations (nursing
homes, universities, prisons, etc.) as well. Similarly, school
outbreaks tend to comprise a greater number of large outbreaks when we
distinguish large outbreaks (involving 50 or more illnesses) from
smaller ones. As the final column of table 3 shows,
51 percent of the school outbreaks over the entire period were large,
compared with 7 percent of the restaurant-related outbreaks, 4 percent
of the private home-related outbreaks, 25 percent of the other
outbreaks, and 10 percent of the outbreaks of unknown origin.
In general, identifying the frequency and causes of school outbreaks in
CDC's data is difficult because reporting of outbreaks to CDC is
voluntary, and the reporting practices of states vary. In table 4, we
show the number of outbreaks reported by each state over the entire
period, classified according to where the food that produced the
outbreak was prepared. The row totals reveal dramatic differences
across states in the number of outbreaks reported over this 27-year
period. Some states, like Delaware, Mississippi, Nevada, South Dakota,
and Wyoming, reported fewer than
30 outbreaks in total, or only about 1 outbreak per year. Other states,
like California, Florida, and Washington, reported over 1,000 outbreaks
in the period, and New York reported over 3,000. States also differed
in the locations in which their reported outbreaks occurred. While some
states reported 20 or more school outbreaks in the 27-year period,
other states reported only 1 or 2. Similar disparities exist across
states in the percentage of outbreaks resulting from restaurant foods
(ranging from
8 percent in Alaska to 73 percent in Washington) and in the percentage
of outbreaks resulting from foods prepared in private homes (ranging
from
4 percent in Arkansas to 50 percent in Alaska).
Some of these discrepancies may be due to differences among states in
population and in such characteristics as the number of restaurants and
the eating habits of residents. However, these differences in the
number of reported outbreaks persist even after differences in
population are crudely controlled. In table 5, we show the number of
outbreaks over the entire period as a function of population size by
dividing the number of outbreaks by the population of each state
averaged from the 1970, 1980, 1990, and 2000 Censuses. The rate of
outbreaks per 100,000 individuals during the 27-year period ranged from
only 1 or 2 per 100,000 in some states to nearly 20, 30, or more than
60 per 100,000 in others. These data demonstrate that states with the
largest number of reported outbreaks are not necessarily those with the
largest populations. Moreover, the patterns in the 5 states reporting
the largest numbers of outbreaks (see table 6 and figure 5) are
extremely disparate. While the increase in the number of outbreaks in
Ohio and the sizable decrease in the number of outbreaks in New York
since the early 1980s may reflect declines or improvements in food
handling or preparation in each state over time, these outbreak
patterns probably also involve changes in how each state reports
foodborne outbreaks.[Footnote 39]
After we completed our analysis, CDC published foodborne outbreak data
for 2000 on its website. In 2000, 67 of the 1,413 reported outbreaks
occurred in schools. These 67 outbreaks caused 2,987 illnesses.
However, the 2000 data are not comparable to the numbers of school
outbreaks discussed elsewhere in this report, because we refined the
1973 through 1999 data to exclude, for example, colleges and
universities.
Table 1: Number of Reported Foodborne Outbreaks and Related Illnesses,
Hospitalizations, and Deaths, 1973-1999:
Year: 1973-75; Outbreaks: 1,260; Illnesses: 48,537; Hospitalizations:
1,906; Fatalities: 41.
Year: 1976-78; Outbreaks: 1,393; Illnesses: 34,357; Hospitalizations:
1,833; Fatalities: 21.
Year: 1979-81; Outbreaks: 1,739; Illnesses: 43,057; Hospitalizations:
2,177; Fatalities: 66.
Year: 1982-84; Outbreaks: 1,712; Illnesses: 51,159; Hospitalizations:
2,086; Fatalities: 76.
Year: 1985-87; Outbreaks: 1,381; Illnesses: 63,004; Hospitalizations:
4,328; Fatalities: 94.
Year: 1988-90; Outbreaks: 1,489; Illnesses: 50,830; Hospitalizations:
2,349; Fatalities: 57.
Year: 1991-93; Outbreaks: 1,456; Illnesses: 40,215; Hospitalizations:
1,735; Fatalities: 31.
Year: 1994-96; Outbreaks: 1,937; Illnesses: 45,913; Hospitalizations:
1,692; Fatalities: 21.
Year: 1997-99; Outbreaks: 3,464; Illnesses: 70,411; Hospitalizations:
2,013; Fatalities: 47.
Year: Total; Outbreaks: 15,831; Illnesses: 447,483; Hospitalizations:
20,119; Fatalities: 457.
Source: GAO analysis of CDC data.
Note: The number of illnesses were reported for all outbreaks, though
for 1 outbreak no illnesses were reported, and for 326 (2.1 percent) of
the outbreaks only one illness was reported. The number of
hospitalizations were not reported for 3,379 (21.3 percent) of the
15,831 outbreaks, and the number of fatalities were not reported for
2,638 (16.7 percent) of the 15,831 outbreaks.
[End of table]
Table 2: Number of Reported Foodborne Outbreaks Resulting from Foods
Prepared in Restaurants, Private Homes, Schools, and in Other
Locations, 1973-1999:
[See PDF for image]
Source: GAO analysis of CDC data.
Note: Restaurants include delicatessens and cafeterias. For our
analysis, we excluded universities and colleges from the schools
category. The other category includes churches, caterers, grocery
stores, nursing homes, camps, and prisons.
[End of table]
Table 3: Number of Illnesses Associated with Reported Foodborne
Outbreaks Resulting from Foods Prepared in Restaurants, Private Homes,
Schools, and in Other Locations, 1973-1999:
(Continued From Previous Page)
Location of food preparation: Restaurant; Outbreaks: 8,465; Illnesses:
148,548; Illnesses per outbreak: 17.5; Percent of outbreaks with 50+
illnesses: 7.3%.
Location of food preparation: Private home; Outbreaks: 2,404;
Illnesses: 30,198; Illnesses per outbreak: 12.6; Percent of outbreaks
with 50+ illnesses: 3.8%.
Location of food preparation: School; Outbreaks: 547; Illnesses:
46,461; Illnesses per outbreak: 84.9; Percent of outbreaks with 50+
illnesses: 50.5%.
Location of food preparation: Other; Outbreaks: 3,704; Illnesses:
207,191; Illnesses per outbreak: 55.9; Percent of outbreaks with 50+
illnesses: 25.0%.
Location of food preparation: Unknown; Outbreaks: 711; Illnesses:
15,085; Illnesses per outbreak: 21.2; Percent of outbreaks with 50+
illnesses: 9.8%.
Location of food preparation: Total; Outbreaks: 15,831; Illnesses:
447,483; Illnesses per outbreak: 28.3; Percent of outbreaks with 50+
illnesses: 12.5%.
[End of table]
Source: GAO analysis of CDC data.
Table 4: Number of Illnesses Associated with Reported Foodborne
Outbreaks Resulting from Foods Prepared in Restaurants, Private Homes,
Schools, and in Other Locations, by State, 1973-1999:
State: Alaska; Restaurant: 11; Home: 68; School: 2; Other: 27; Unknown:
29; Total: 137.
Restaurant: 8.0%; Home: 49.6%; School: 1.5%; Other:
19.7%; Unknown: 21.2%; Total: 100.0%.
State: Alabama; Restaurant: 90; Home: 15; School: 12; Other: 18;
Unknown: 1; Total: 136.
Restaurant: 66.2%; Home: 11.0%; School: 8.8%; Other:
13.2%; Unknown: .7%; Total: 100.0%.
State: Arkansas; Restaurant: 8; Home: 1; School: 3; Other: 13; Unknown:
0; Total: 25.
Restaurant: 32.0%; Home: 4.0%; School: 12.0%; Other:
52.0%; Unknown: 0%; Total: 100.0%.
State: Arizona; Restaurant: 37; Home: 21; School: 7; Other: 35;
Unknown: 3; Total: 103.
Restaurant: 35.9%; Home: 20.4%; School: 6.8%; Other:
34.0%; Unknown: 2.9%; Total: 100.0%.
State: California; Restaurant: 533; Home: 231; School: 27; Other: 305;
Unknown: 61; Total: 1,157.
Restaurant: 46.1%; Home: 20.0%; School: 2.3%; Other:
26.4%; Unknown: 5.3%; Total: 100.0%.
State: Colorado; Restaurant: 59; Home: 21; School: 2; Other: 33;
Unknown: 4; Total: 119.
Restaurant: 49.6%; Home: 17.6%; School: 1.7%; Other:
27.7%; Unknown: 3.4%; Total: 100.0%.
State: Connecticut; Restaurant: 102; Home: 41; School: 21; Other: 89;
Unknown: 8; Total: 261.
Restaurant: 39.1%; Home: 15.7%; School: 8.0%; Other:
34.1%; Unknown: 3.1%; Total: 100.0%.
State: District of Columbia; Restaurant: 15; Home: 2; School: 4; Other:
11; Unknown: 0; Total: 32.
Restaurant: 46.9%; Home: 6.3%; School: 12.5%; Other:
34.4%; Unknown: 0%; Total: 100.0%.
State: Delaware; Restaurant: 8; Home: 3; School: 2; Other: 13; Unknown:
1; Total: 27.
Restaurant: 29.6%; Home: 11.1%; School: 7.4%; Other:
48.1%; Unknown: 3.7%; Total: 100.0%.
State: Florida; Restaurant: 675; Home: 122; School: 28; Other: 181;
Unknown: 33; Total: 1,039.
Restaurant: 65.0%; Home: 11.7%; School: 2.7%; Other:
17.4%; Unknown: 3.2%; Total: 100.0%.
State: Georgia; Restaurant: 64; Home: 22; School: 24; Other: 45;
Unknown: 8; Total: 163.
Restaurant: 39.3%; Home: 13.5%; School: 14.7%; Other:
27.6%; Unknown: 4.9%; Total: 100.0%.
State: Hawaii; Restaurant: 215; Home: 316; School: 6; Other: 89;
Unknown: 43; Total: 669.
Restaurant: 32.1%; Home: 47.2%; School: .9%; Other:
13.3%; Unknown: 6.4%; Total: 100.0%.
State: Iowa; Restaurant: 48; Home: 20; School: 3; Other: 26; Unknown:
2; Total: 99.
Restaurant: 48.5%; Home: 20.2%; School: 3.0%; Other:
26.3%; Unknown: 2.0%; Total: 100.0%.
State: Idaho; Restaurant: 42; Home: 17; School: 1; Other: 18; Unknown:
4; Total: 82.
Restaurant: 51.2%; Home: 20.7%; School: 1.2%; Other:
22.0%; Unknown: 4.9%; Total: 100.0%.
State: Illinois; Restaurant: 292; Home: 61; School: 22; Other: 176;
Unknown: 12; Total: 563.
Restaurant: 51.9%; Home: 10.8%; School: 3.9%; Other:
31.3%; Unknown: 2.1%; Total: 100.0%.
State: Indiana; Restaurant: 43; Home: 8; School: 3; Other: 40; Unknown:
5; Total: 99.
Restaurant: 43.4%; Home: 8.1%; School: 3.0%; Other:
40.4%; Unknown: 5.1%; Total: 100.0%.
State: Kansas; Restaurant: 30; Home: 6; School: 6; Other: 16; Unknown:
3; Total: 61.
Restaurant: 49.2%; Home: 9.8%; School: 9.8%; Other:
26.2%; Unknown: 4.9%; Total: 100.0%.
State: Kentucky; Restaurant: 23; Home: 15; School: 3; Other: 20;
Unknown: 7; Total: 68.
Restaurant: 33.8%; Home: 22.1%; School: 4.4%; Other:
29.4%; Unknown: 10.3%; Total: 100.0%.
State: Louisiana; Restaurant: 15; Home: 20; School: 9; Other: 33;
Unknown: 6; Total: 83.
Restaurant: 18.1%; Home: 24.1%; School: 10.8%; Other:
39.8%; Unknown: 7.2%; Total: 100.0%.
State: Massachusetts; Restaurant: 133; Home: 28; School: 25; Other:
118; Unknown: 19; Total: 323.
Restaurant: 41.2%; Home: 8.7%; School: 7.7%; Other:
36.5%; Unknown: 5.9%; Total: 100.0%.
State: Maryland; Restaurant: 341; Home: 47; School: 7; Other: 105;
Unknown: 15; Total: 515.
Restaurant: 66.2%; Home: 9.1%; School: 1.4%; Other:
20.4%; Unknown: 2.9%; Total: 100.0%.
State: Maine; Restaurant: 37; Home: 6; School: 2; Other: 30; Unknown:
1; Total: 76.
Restaurant: 48.7%; Home: 7.9%; School: 2.6%; Other:
39.5%; Unknown: 1.3%; Total: 100.0%.
State: Michigan; Restaurant: 236; Home: 21; School: 16; Other: 80;
Unknown: 100; Total: 453.
Restaurant: 52.1%; Home: 4.6%; School: 3.5%; Other:
17.7%; Unknown: 22.1%; Total: 100.0%.
State: Minnesota; Restaurant: 204; Home: 53; School: 19; Other: 131;
Unknown: 11; Total: 418.
Restaurant: 48.8%; Home: 12.7%; School: 4.5%; Other:
31.3%; Unknown: 2.6%; Total: 100.0%.
State: Missouri; Restaurant: 78; Home: 13; School: 17; Other: 47;
Unknown: 3; Total: 158.
Restaurant: 49.4%; Home: 8.2%; School: 10.8%; Other:
29.7%; Unknown: 1.9%; Total: 100.0%.
State: Mississippi; Restaurant: 10; Home: 3; School: 2; Other: 10;
Unknown: 0; Total: 25.
Restaurant: 40.0%; Home: 12.0%; School: 8.0%; Other:
40.0%; Unknown: 0%; Total: 100.0%.
State: Montana; Restaurant: 12; Home: 7; School: 2; Other: 7; Unknown:
13; Total: 41.
Restaurant: 29.3%; Home: 17.1%; School: 4.9%; Other:
17.1%; Unknown: 31.7%; Total: 100.0%.
State: North Carolina; Restaurant: 44; Home: 5; School: 6; Other: 46;
Unknown: 4; Total: 105.
Restaurant: 41.9%; Home: 4.8%; School: 5.7%; Other:
43.8%; Unknown: 3.8%; Total: 100.0%.
State: North Dakota; Restaurant: 14; Home: 12; School: 4; Other: 10;
Unknown: 4; Total: 44.
Restaurant: 31.8%; Home: 27.3%; School: 9.1%; Other:
22.7%; Unknown: 9.1%; Total: 100.0%.
State: Nebraska; Restaurant: 26; Home: 12; School: 2; Other: 19;
Unknown: 1; Total: 60.
Restaurant: 43.3%; Home: 20.0%; School: 3.3%; Other:
31.7%; Unknown: 1.7%; Total: 100.0%.
State: New Hampshire; Restaurant: 21; Home: 3; School: 10; Other: 22;
Unknown: 2; Total: 58.
Restaurant: 36.2%; Home: 5.2%; School: 17.2%; Other:
37.9%; Unknown: 3.4%; Total: 100.0%.
State: New Jersey; Restaurant: 143; Home: 45; School: 13; Other: 103;
Unknown: 17; Total: 321.
Restaurant: 44.5%; Home: 14.0%; School: 4.0%; Other:
32.1%; Unknown: 5.3%; Total: 100.0%.
State: New Mexico; Restaurant: 52; Home: 24; School: 8; Other: 23;
Unknown: 7; Total: 114.
Restaurant: 45.6%; Home: 21.1%; School: 7.0%; Other:
20.2%; Unknown: 6.1%; Total: 100.0%.
State: Nevada; Restaurant: 13; Home: 4; School: 0; Other: 8; Unknown:
4; Total: 29.
Restaurant: 44.8%; Home: 13.8%; School: 0%; Other:
27.6%; Unknown: 13.8%; Total: 100.0%.
State: New York; Restaurant: 2,095; Home: 349; School: 72; Other: 636;
Unknown: 67; Total: 3,219.
Restaurant: 65.1%; Home: 10.8%; School: 2.2%; Other:
19.8%; Unknown: 2.1%; Total: 100.0%.
State: Ohio; Restaurant: 463; Home: 103; School: 21; Other: 144;
Unknown: 20; Total: 751.
Restaurant: 61.7%; Home: 13.7%; School: 2.8%; Other:
19.2%; Unknown: 2.7%; Total: 100.0%.
State: Oklahoma; Restaurant: 22; Home: 15; School: 5; Other: 19;
Unknown: 3; Total: 64.
Restaurant: 34.4%; Home: 23.4%; School: 7.8%; Other:
29.7%; Unknown: 4.7%; Total: 100.0%.
State: Oregon; Restaurant: 69; Home: 44; School: 10; Other: 41;
Unknown: 24; Total: 188.
Restaurant: 36.7%; Home: 23.4%; School: 5.3%; Other:
21.8%; Unknown: 12.8%; Total: 100.0%.
State: Pennsylvania; Restaurant: 305; Home: 154; School: 24; Other:
207; Unknown: 33; Total: 723.
Restaurant: 42.2%; Home: 21.3%; School: 3.3%; Other:
28.6%; Unknown: 4.6%; Total: 100.0%.
State: Rhode Island; Restaurant: 8; Home: 10; School: 5; Other: 8;
Unknown: 2; Total: 33.
Restaurant: 24.2%; Home: 30.3%; School: 15.2%; Other:
24.2%; Unknown: 6.1%; Total: 100.0%.
State: South Carolina; Restaurant: 33; Home: 13; School: 2; Other: 17;
Unknown: 2; Total: 67.
Restaurant: 49.3%; Home: 19.4%; School: 3.0%; Other:
25.4%; Unknown: 3.0%; Total: 100.0%.
State: South Dakota; Restaurant: 10; Home: 6; School: 1; Other: 5;
Unknown: 0; Total: 22.
Restaurant: 45.5%; Home: 27.3%; School: 4.5%; Other:
22.7%; Unknown: 0%; Total: 100.0%.
State: Tennessee; Restaurant: 45; Home: 18; School: 8; Other: 27;
Unknown: 2; Total: 100.
Restaurant: 45.0%; Home: 18.0%; School: 8.0%; Other:
27.0%; Unknown: 2.0%; Total: 100.0%.
State: Texas; Restaurant: 104; Home: 25; School: 15; Other: 53;
Unknown: 43; Total: 240.
Restaurant: 43.3%; Home: 10.4%; School: 6.3%; Other:
22.1%; Unknown: 17.9%; Total: 100.0%.
State: Utah; Restaurant: 22; Home: 25; School: 3; Other: 9; Unknown: 0;
Total: 59.
Restaurant: 37.3%; Home: 42.4%; School: 5.1%; Other:
15.3%; Unknown: 0%; Total: 100.0%.
State: Virginia; Restaurant: 94; Home: 37; School: 13; Other: 80;
Unknown: 11; Total: 235.
Restaurant: 40.0%; Home: 15.7%; School: 5.5%; Other:
34.0%; Unknown: 4.7%; Total: 100.0%.
State: Vermont; Restaurant: 23; Home: 10; School: 11; Other: 34;
Unknown: 0; Total: 78.
Restaurant: 29.5%; Home: 12.8%; School: 14.1%; Other:
43.6%; Unknown: 0%; Total: 100.0%.
State: Washington; Restaurant: 1,233; Home: 175; School: 13; Other:
238; Unknown: 39; Total: 1,698.
Restaurant: 72.6%; Home: 10.3%; School: .8%; Other:
14.0%; Unknown: 2.3%; Total: 100.0%.
State: Wisconsin; Restaurant: 217; Home: 53; School: 20; Other: 134;
Unknown: 15; Total: 439.
Restaurant: 49.4%; Home: 12.1%; School: 4.6%; Other:
30.5%; Unknown: 3.4%; Total: 100.0%.
State: West Virginia; Restaurant: 5; Home: 10; School: 3; Other: 12;
Unknown: 1; Total: 31.
Restaurant: 16.1%; Home: 32.3%; School: 9.7%; Other:
38.7%; Unknown: 3.2%; Total: 100.0%.
State: Wyoming; Restaurant: 5; Home: 5; School: 2; Other: 2; Unknown:
0; Total: 14.
Restaurant: 35.7%; Home: 35.7%; School: 14.3%; Other:
14.3%; Unknown: 0%; Total: 100.0%.
State: Total; Restaurant: 8,427; Home: 2,345; School: 546; Other:
3,613; Unknown: 693; Total: 15,624.
Restaurant: 53.9%; Home: 15.0%; School: 3.5%; Other:
23.1%; Unknown: 4.4%; Total: 100.0%.
Source: GAO analysis of CDC data.
[End of table]
Table 5: Reported Foodborne Outbreaks Per 100,000 Population, by State,
1973-1999:
State: Alaska; Averaged population[A]: 470,352; Outbreaks: 137;
Outbreaks per: 100,000 population: 29.1.
State: Alabama; Averaged population[A]: 3,956,482; Outbreaks: 136;
Outbreaks per: 100,000 population: 3.4.
State: Arkansas; Averaged population[A]: 2,308,471; Outbreaks: 25;
Outbreaks per: 100,000 population: 1.1.
State: Arizona; Averaged population[A]: 3,322,369; Outbreaks: 103;
Outbreaks per: 100,000 population: 3.1.
State: California; Averaged population[A]: 26,817,660; Outbreaks:
1,157; Outbreaks per: 100,000 population: 4.3.
State: Colorado; Averaged population[A]: 3,173,804; Outbreaks: 119;
Outbreaks per: 100,000 population: 3.8.
State: Connecticut; Averaged population[A]: 3,208,119; Outbreaks:
261; Outbreaks per: 100,000 population: 8.1.
State: District of Columbia; Averaged population[A]: 643,490;
Outbreaks: 32; Outbreaks per: 100,000 population: 5.0.
State: Delaware; Averaged population[A]: 648,053; Outbreaks: 27;
Outbreaks per: 100,000 population: 4.2.
State: Florida; Averaged population[A]: 11,364,512; Outbreaks: 1,039;
Outbreaks per: 100,000 population: 9.1.
State: Georgia; Averaged population[A]: 6,178,926; Outbreaks: 163;
Outbreaks per: 100,000 population: 2.6.
State: Hawaii; Averaged population[A]: 1,013,593; Outbreaks: 669;
Outbreaks per: 100,000 population: 66.0.
State: Iowa; Averaged population[A]: 2,860,564; Outbreaks: 99;
Outbreaks per: 100,000 population: 3.5.
State: Idaho; Averaged population[A]: 989,413; Outbreaks: 82;
Outbreaks per: 100,000 population: 8.3.
State: Illinois; Averaged population[A]: 11,596,675; Outbreaks: 563;
Outbreaks per: 100,000 population: 4.9.
State: Indiana; Averaged population[A]: 5,577,565; Outbreaks: 99;
Outbreaks per: 100,000 population: 1.8.
State: Kansas; Averaged population[A]: 2,444,686; Outbreaks: 61;
Outbreaks per: 100,000 population: 2.5.
State: Kentucky; Averaged population[A]: 3,652,138; Outbreaks: 68;
Outbreaks per: 100,000 population: 1.9.
State: Louisiana; Averaged population[A]: 4,134,872; Outbreaks: 83;
Outbreaks per: 100,000 population: 2.0.
State: Massachusetts; Averaged population[A]: 5,947,932; Outbreaks:
323; Outbreaks per: 100,000 population: 5.4.
State: Maryland; Averaged population[A]: 4,554,707; Outbreaks: 515;
Outbreaks per: 100,000 population: 11.3.
State: Maine; Averaged population[A]: 1,155,308; Outbreaks: 76;
Outbreaks per: 100,000 population: 6.6.
State: Michigan; Averaged population[A]: 9,344,411; Outbreaks: 453;
Outbreaks per: 100,000 population: 4.9.
State: Minnesota; Averaged population[A]: 4,294,163; Outbreaks: 418;
Outbreaks per: 100,000 population: 9.7.
State: Missouri; Averaged population[A]: 5,076,648; Outbreaks: 158;
Outbreaks per: 100,000 population: 3.1.
State: Mississippi; Averaged population[A]: 2,538,877; Outbreaks: 25;
Outbreaks per: 100,000 population: 1.0.
State: Montana; Averaged population[A]: 795,590; Outbreaks: 41;
Outbreaks per: 100,000 population: 5.2.
State: North Carolina; Averaged population[A]: 6,411,032; Outbreaks:
105; Outbreaks per: 100,000 population: 1.6.
State: North Dakota; Averaged population[A]: 637,877; Outbreaks: 44;
Outbreaks per: 100,000 population: 6.9.
State: Nebraska; Averaged population[A]: 1,586,202; Outbreaks: 60;
Outbreaks per: 100,000 population: 3.8.
State: New Hampshire; Averaged population[A]: 1,000,832; Outbreaks:
58; Outbreaks per: 100,000 population: 5.8.
State: New Jersey; Averaged population[A]: 7,670,118; Outbreaks: 321;
Outbreaks per: 100,000 population: 4.2.
State: New Mexico; Averaged population[A]: 1,413,516; Outbreaks: 114;
Outbreaks per: 100,000 population: 8.1.
State: Nevada; Averaged population[A]: 1,122,330; Outbreaks: 29;
Outbreaks per: 100,000 population: 2.6.
State: New York; Averaged population[A]: 18,191,594; Outbreaks:
3,219; Outbreaks per: 100,000 population: 17.7.
State: Ohio; Averaged population[A]: 10,913,827; Outbreaks: 751;
Outbreaks per: 100,000 population: 6.9.
State: Oklahoma; Averaged population[A]: 3,045,248; Outbreaks: 64;
Outbreaks per: 100,000 population: 2.1.
State: Oregon; Averaged population[A]: 2,747,090; Outbreaks: 188;
Outbreaks per: 100,000 population: 6.8.
State: Pennsylvania; Averaged population[A]: 11,956,840; Outbreaks:
723; Outbreaks per: 100,000 population: 6.1.
State: Rhode Island; Averaged population[A]: 987,165; Outbreaks: 33;
Outbreaks per: 100,000 population: 3.3.
State: South Carolina; Averaged population[A]: 3,302,812; Outbreaks:
67; Outbreaks per: 100,000 population: 2.0.
State: South Dakota; Averaged population[A]: 701,968; Outbreaks: 22;
Outbreaks per: 100,000 population: 3.1.
State: Tennessee; Averaged population[A]: 4,770,902; Outbreaks: 100;
Outbreaks per: 100,000 population: 2.1.
State: Texas; Averaged population[A]: 15,816,544; Outbreaks: 240;
Outbreaks per: 100,000 population: 1.5.
State: Utah; Averaged population[A]: 1,619,082; Outbreaks: 59;
Outbreaks per: 100,000 population: 3.6.
State: Virginia; Averaged population[A]: 5,816,035; Outbreaks: 235;
Outbreaks per: 100,000 population: 4.0.
State: Vermont; Averaged population[A]: 531,943; Outbreaks: 78;
Outbreaks per: 100,000 population: 14.7.
State: Washington; Averaged population[A]: 4,576,553; Outbreaks:
1,698; Outbreaks per: 100,000 population: 37.1.
State: Wisconsin; Averaged population[A]: 4,844,758; Outbreaks: 439;
Outbreaks per: 100,000 population: 9.1.
State: West Virginia; Averaged population[A]: 1,823,926; Outbreaks:
31; Outbreaks per: 100,000 population: 1.7.
State: Wyoming; Averaged population[A]: 437,336; Outbreaks: 14;
Outbreaks per: 100,000 population: 3.2.
Source: GAO analysis of CDC data.
[A] Population data were obtained from the U.S. Census Bureau.
Population is averaged over the 1970, 1980, 1990, and 2000 Census data.
[End of table]
Table 6: Number of Reported Foodborne Outbreaks in Five States
Reporting the Largest Numbers, 1973-1999:
Year: 1973-75; California: 111; Florida: 47; New York: 155; Ohio: 22;
Washington: 148; Total: 483.
Year: 1976-78; California: 120; Florida: 25; New York: 380; Ohio: 13;
Washington: 143; Total: 681.
Year: 1979-81; California: 128; Florida: 52; New York: 530; Ohio: 43;
Washington: 163; Total: 916.
Year: 1982-84; California: 104; Florida: 49; New York: 658; Ohio: 15;
Washington: 125; Total: 951.
Year: 1985-87; California: 100; Florida: 27; New York: 410; Ohio: 19;
Washington: 162; Total: 718.
Year: 1988-90; California: 35; Florida: 45; New York: 335; Ohio: 59;
Washington: 107; Total: 581.
Year: 1991-93; California: 95; Florida: 38; New York: 297; Ohio: 61;
Washington: 221; Total: 712.
Year: 1994-96; California: 176; Florida: 140; New York: 250; Ohio: 232;
Washington: 381; Total: 1179.
Year: 1997-99; California: 288; Florida: 616; New York: 204; Ohio: 287;
Washington: 248; Total: 1643.
Year: Total; California: 1,157; Florida: 1,039; New York: 3,219; Ohio:
751; Washington: 1,698; Total: 7,864.
Source: GAO analysis of CDC data.
[End of table]
Figure 2: Total Number of Reported Outbreaks, 1973-1999:
[See PDF for image]
Note: For 1997-1999, CDC attributes much of the increases in reported
outbreaks to improved data collection procedures initiated in 1998.
[End of figure]
Figure 3: Total Number of Illness Associated with Reported Outbreaks,
1973-1999:
[See PDF for image]
Note: For 1997-1999, CDC attributes some of the increases in reported
outbreaks to improved data collection procedures initiated in 1998.
[End of figure]
Figure 4: Number of Reported Outbreaks, by Where Food Was Prepared,
1973-1999:
[See PDF for image]
Note: For 1997-1999, CDC attributes some of the increases in reported
outbreaks to improved data collection procedures initiated in 1998.
[End of figure]
Figure 5: Number of Outbreaks in States Reporting the Largest Number of
Outbreaks, 1973-1999:
[See PDF for image]
Note: For 1997-1999, CDC attributes some of the increases in reported
outbreaks to improved data collection procedures initiated in 1998.
This figure depicts the states reporting the largest number of
outbreaks over the time period, not the states with the largest
populations.
[End of figure]
[End of section]
Appendix IV: Food Safety and Security Practices for School Meal Programs
Used or Suggested by Government or Private Sector:
School districts, government agencies, and the private sector use or
suggest useful food safety and security practices for school meal
programs. Table 7 presents these practices, which are classified into
two main categories--food safety and food security. For both main
categories, the most frequently cited specific categories appears
first. For example, for food safety the specific category of training
and certification was most frequently cited and thus appears first.
Similarly, within each category the most frequently cited practice
appears first. Table 7 also describes the food safety or security
benefit of each practice and indicates the type of entity that uses or
suggests each practice. Some of the practices and suggestions listed in
the table may not be practical for all school districts, especially
those that are resource-constrained from either the state or local
levels.[Footnote 40]
Table 7 is not intended to be an all-encompassing primer on food safety
and security, but rather a compilation of useful practices that we
observed or discussed with entities we contacted during our review.
Some of the practices cited are components of larger food safety
concepts. For more complete information on food safety, FNS suggests
that interested parties may reference the extensive support materials
prepared by the National Food Service Management Institute, which may
be accessed at www.nfsmi.org. As stated earlier, appropriate security
practices will be available in the forthcoming FNS security guidelines
for schools. FNS believes that some of the practices as cited may not
reflect the views of or be endorsed by national school organizations or
leaders in food industry. Obtaining such endorsements was beyond the
scope of our review.
Table 7: Food Safety and Security Practices for School Meal Programs
Used or Suggested by Government or Private Sector:
Useful practices and suggestions: FOOD SAFETY: 1. Training and
certification:
Useful practices and suggestions: Require certification of at least one
food service worker in each school kitchen by use of established
certification programs or through self-or state-developed courses;
Benefits: Enhances food safety and establishes a standard for food
safety education; School districts: Yes; Federal agencies: Yes;
State and local agencies: Yes; Private sector: Yes.
Useful practices and suggestions: Require or provide ongoing documented
training for food service workers in food safety topics such as
controlling food inventory, handling leftovers, receiving and storing
food, using written cleaning and sanitation procedures, maintaining
proper temperatures, and packaging; Benefits: Reinforces proper food
safety practices and facilitates learning; School districts: Yes;
Federal agencies: Yes; State and local agencies: Yes;
Private sector: Yes.
Useful practices and suggestions: Have local health department monitor
certification requirements; Benefits: Enforces compliance with food
safety requirements; School districts: Yes; Federal agencies: Yes;
State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Use multilingual training courses and
post food safety messages in languages other than English or in
graphics that do not require language instruction; Benefits: Promotes
training in and understanding of food safety among all food service
workers; School districts: Yes; Federal agencies: Yes; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Require all food safety trainers to
be certified; Benefits: Establishes a standard for food safety
education; School districts: No; Federal agencies: No; State
and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Train workers on critical control
points of HACCP at each food service workstation; Benefits:
Facilitates food safety training; School districts: No; Federal
agencies: No; State and local agencies: No; Private sector:
Yes.
Useful practices and suggestions: Communicate importance of food safety
through video screening that includes children who got sick from
foodborne illness; Benefits: Facilitates food safety training and
reinforces seriousness of impacts of foodborne illness; School
districts: No; Federal agencies: No; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: 2. Risk-based food safety concepts;
Benefits: No; School districts: No; Federal agencies:
No; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Mandate and document self-
inspections, such as HACCP checklists provided by USDA, at each
school; Benefits: Promotes use of risk-based food safety procedures
and increases monitoring; School districts: Yes; Federal agencies:
Yes; State and local agencies: Yes; Private sector: Yes.
Useful practices and suggestions: Have USDA develop and disseminate
generic HACCP plans for school districts, such as a template. HACCP
plans would be individualized to school's food service operations;
Benefits: Promotes use of risk-based food safety procedures and
establishes a common standard for food safety practices; School
districts: Yes; Federal agencies: Yes; State and local agencies: No;
Private sector: Yes.
Useful practices and suggestions: Use HACCP-based food safety concepts
throughout school food service operations, such as hygiene, time and
temperature controls, prevention of cross contamination,
documentation, training, and self-inspection; Benefits: Promotes use
of risk-based food safety procedures and establishes common standard
for food safety practices; School districts: Yes; Federal agencies:
Yes; State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Adopt and use standardized recipes
with critical control points; Benefits: Promotes use of risk-based
food safety procedures; School districts: Yes; Federal agencies: Yes;
State and local agencies: Yes; Private sector: No.
Useful practices and suggestions: Record and/or check temperatures of
refrigerators, freezers, delivery trucks, and high-risk foods
periodically each day, including maintaining temperature and daily
production records for support and satellite schools and calibration of
thermometers; Benefits: Helps ensure proper food preparation,
facilitates monitoring, helps detect any spoilage due to improper food
holding, and ensures accuracy of food temperatures; School districts:
Yes; Federal agencies: Yes; State and local agencies: Yes; Private
sector: No.
Useful practices and suggestions: Provide templates for different types
of food preparation, such as cooking meat, reheating foods, using
prepackaged meals, and preparing salads; Benefits: Promotes use of
risk-based food safety procedures and establishes common standard for
food safety practices; School districts: No; Federal agencies:
No; State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Adopt food safety measures that
exceed the current FDA Food Code, such as maintaining temperature logs,
requiring double hand washing by food service workers after they use
the rest room, or heating premade or precooked food items, such as
pizza, to higher temperatures while retaining food quality and
palatability; Benefits: Provides additional food safety protection;
School districts: Yes; Federal agencies: No; State and local
agencies: Yes; Private sector: No.
Useful practices and suggestions: Require school district authorities
to perform food safety inspections of schools twice a month or when
visiting schools; Benefits: Increases monitoring of schools' food
safety practices; School districts: Yes; Federal agencies: Yes; State
and local agencies: No; Private sector: No.
Useful practices and suggestions: Adopt basic health standards for food
service employees that handle foods, such as preventing employees who
are coughing and sneezing from working; Benefits: Minimizes risk of
pathogens spread by ill workers; School districts: No; Federal
agencies: Yes; State and local agencies: Yes; Private sector: No.
Useful practices and suggestions: Require suppliers to use HACCP plans
or food safety and quality control programs in their manufacturing
practices; Benefits: Decreases likelihood of receiving contaminated
food; School districts: No; Federal agencies: Yes; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: Incorporate critical control points
into school lunch program recipes, which are available on Internet and
CD-ROM, and incorporate new food purchasing guidelines into recipes;
Benefits: Promotes food safety; School districts: No; Federal
agencies: Yes; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Thoroughly wash fresh produce;
Benefits: Provides additional food protection; School districts:
No; Federal agencies: No; State and local agencies: No;
Private sector: Yes.
Useful practices and suggestions: 3. Food storage, handling, and
preparation; Benefits: No; School districts: No; Federal
agencies: No; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Require food service staff to
properly use and change gloves or tongs; Benefits: Avoids exposure to
any pathogens on hands; School districts: Yes; Federal agencies: Yes;
State and local agencies: Yes; Private sector: Yes.
Useful practices and suggestions: Prohibit food deliveries at loading
docks that are not supervised by authorized staff; Benefits: Prevents
potentially contaminated/questionable food products from entering
schools; School districts: Yes; Federal agencies: Yes; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: Develop procedures to address high-
risk foods, such as melons, sprouts, unpasteurized eggs, and salad bar
items; Benefits: Eliminates possible sources of food contamination and
reduces likelihood of contamination; School districts: Yes; Federal
agencies: No; State and local agencies: No; Private sector:
Yes.
Useful practices and suggestions: Require proper cooling procedures,
such as breaking down batches of food into shallow serving pans for
fast chill, immersing wrapped foods in ice for fast cooling, or using
blast chillers; Benefits: Minimizes opportunities for pathogen
growth; School districts: No; Federal agencies: Yes; State and
local agencies: Yes; Private sector: Yes.
Useful practices and suggestions: Spot check deliveries for
temperature, labeling, and packaging and record results; Benefits:
Identifies potentially contaminated incoming food products; School
districts: No; Federal agencies: Yes; State and local agencies:
No; Private sector: Yes.
Useful practices and suggestions: Mark dates on all delivered items and
use oldest inventory first; Benefits: Facilitates proper inventory
maintenance; School districts: Yes; Federal agencies: Yes; State and
local agencies: No; Private sector: No.
Useful practices and suggestions: Require staff to wear hats or
hairnets during food preparation and/or service; Benefits: Helps
minimize contamination of foods; School districts: Yes; Federal
agencies: Yes; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Use cutting boards that are color-
coded by food group and sanitize them after each use accordingly;
Benefits: Minimizes cross contamination of foods; School districts:
No; Federal agencies: Yes; State and local agencies: No;
Private sector: Yes.
Useful practices and suggestions: Properly preserve portions of foods
served; Benefits: Allows later food safety testing if problems are
suspected; School districts: Yes; Federal agencies: Yes; State and
local agencies: No; Private sector: No.
Useful practices and suggestions: 4. Nonschool meal foods; Benefits:
No; School districts: No; Federal agencies: No; State
and local agencies: No; Private sector: No.
Useful practices and suggestions: Adopt policy of discouraging or
prohibiting food prepared outside the school from being served or
stored in school facilities; Benefits: Minimizes bringing food into
schools that is prepared elsewhere; School districts: Yes; Federal
agencies: Yes; State and local agencies: Yes; Private sector: No.
Useful practices and suggestions: Require food service staff to be
present whenever school kitchen is used; Benefits: Allows proper
oversight of school facilities; School districts: Yes; Federal
agencies: Yes; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Cater special events from school food
service facility; Benefits: Minimizes bringing food into schools that
is prepared elsewhere; School districts: Yes; Federal agencies: No;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: 5. Product procurement and menu
design; Benefits: No; School districts: No; Federal agencies:
No; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Maximize use of precooked meat and
poultry products; Benefits: Mitigates E. coli O157:H7 and Salmonella
exposure, reduces labor costs, and removes fat from meat and poultry
products; School districts: Yes; Federal agencies: No; State and
local agencies: Yes; Private sector: Yes.
Useful practices and suggestions: Eliminate high-risk foods, such as
alfalfa sprouts, medium-rare hamburgers, and unpasteurized juices;
Benefits: Reduces potential for foodborne contamination; School
districts: No; Federal agencies: Yes; State and local agencies: Yes;
Private sector: Yes.
Useful practices and suggestions: 6. Supplier selection; Benefits:
No; School districts: No; Federal agencies: No; State
and local agencies: No; Private sector: No.
Useful practices and suggestions: Select suppliers that use HACCP or
are more process control oriented (e.g., HACCP-based) and
technologically based; Benefits: Provides criteria for selecting
better quality suppliers; School districts: Yes; Federal agencies:
Yes; State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Allow flexibility in awarding
contracts to the lowest bidder; Benefits: Provides flexibility in
selecting suppliers; School districts: Yes; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: Visit production facilities of all
prospective food suppliers; Benefits: Helps ensure that suppliers use
appropriate food safety practices; School districts: Yes; Federal
agencies: No; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Select suppliers according to food
safety performance by consulting past safety records, independent
auditing results, supplier facility HACCP plans, microbial testing
results of high risk foods and standard operating, storage and recall
procedures; Benefits: Provides criteria for selecting better quality
suppliers and food products; School districts: Yes; Federal agencies:
No; State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Select processors that are approved
by USDA and state agencies when contracting for additional processing
of USDA-donated commodities; Benefits: Provides criteria for selecting
better quality suppliers; School districts: No; Federal agencies:
No; State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: 7. Product specifications; Benefits:
No; School districts: No; Federal agencies: No; State
and local agencies: No; Private sector: No.
Useful practices and suggestions: Award supplier contracts that include
food safety requirements, such as third-party microbiological testing
before foods are delivered to schools and maximum delivery times;
Benefits: Provides additional assurance of food quality by requiring
proper food holding temperatures and minimizing potentially
contaminated food supplies from entering schools; School districts:
Yes; Federal agencies: No; State and local agencies: Yes; Private
sector: No.
Useful practices and suggestions: Apply strictest of USDA, state, or
local standards in specifications required of processing companies;
Benefits: Ensures highest standards for food safety; School districts:
No; Federal agencies: No; State and local agencies: No;
Private sector: Yes.
Useful practices and suggestions: Make food safety-related
specifications on AMS Web page more user friendly; Benefits: Allows
states and districts to use federal procurement expertise; School
districts: No; Federal agencies: Yes; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Apply AMS's procurement
specifications for donated commodities that exceed minimum standards of
regulatory agencies to schools' commercial food purchases; Benefits:
Enhances food safety of school children; School districts: No;
Federal agencies: Yes; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Use assistance available from AMS to
school districts or states in developing contract or product
specifications; Benefits: Allows states and districts to use federal
procurement expertise; School districts: No; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: Have state education department and
local health agencies collaborate in establishing bacteriological
standards for vendor contracts; Benefits: Provides schools with
expertise from relevant agencies for purchasing food products; School
districts: No; Federal agencies: Yes; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Review microbial testing guidelines
of manufacturers; Benefits: Ensures adequacy of testing standards;
School districts: No; Federal agencies: No; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: Perform microbiological testing of
food products after delivery to schools; Benefits: Provides additional
assurance of food quality; School districts: Yes; Federal agencies:
No; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Serve only domestic products in
school meal programs; Benefits: Eliminates threat of pathogens from
foreign countries; School districts: No; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: 8. Auditing/monitoring suppliers;
Benefits: No; School districts: No; Federal agencies:
No; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Require AMS or other third-party
review of production facilities used by new and repeat vendors or food
service management companies; Benefits: Helps ensure that suppliers
use appropriate food safety practices; School districts: Yes; Federal
agencies: Yes; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Require food service management
companies to provide information on their suppliers by revising federal
prototype; Benefits: Facilitates trace back of contaminated food;
School districts: Yes; Federal agencies: No; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Monitor suppliers throughout contract
terms, perform monthly product testing, and work with suppliers to
correct defects; Benefits: Helps ensure that suppliers use appropriate
food safety and security practices; School districts: No; Federal
agencies: No; State and local agencies: No; Private sector:
Yes.
Useful practices and suggestions: Include trace back provisions in
supplier contracts and require suppliers to notify when it provides
products not from preapproved sites; Benefits: Facilitates traceback
of contaminated food; School districts: No; Federal agencies: Yes;
State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Perform routine monitoring of
contract specifications to obtain supplier's compliance with terms of
contract; Benefits: Helps ensure that suppliers use appropriate food
safety and security practices; School districts: No; Federal
agencies: No; State and local agencies: No; Private sector:
Yes.
Useful practices and suggestions: Use product specifications and
routine monitoring of suppliers to ensure bacterial control of critical
items, such as ground meat and poultry; Benefits: Helps ensure that
suppliers use appropriate food safety and security practices; School
districts: No; Federal agencies: Yes; State and local agencies:
No; Private sector: Yes.
Useful practices and suggestions: Compare school vendor performance
information with that of surrounding school jurisdictions; Benefits:
Helps ensure that foods are purchased from reputable suppliers; School
districts: Yes; Federal agencies: No; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Require food brokers and manufacturer
representatives to inspect processors for quality; Benefits: Provides
additional food quality assurance; School districts: Yes; Federal
agencies: No; State and local agencies: No; Private sector:
No.
Useful practices and suggestions: Require suppliers to have third-party
food safety inspections at least once a year; Benefits: Helps ensure
that suppliers use appropriate food safety and security practices;
School districts: No; Federal agencies: No; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: 9. Equipment and facilities;
Benefits: No; School districts: No; Federal agencies:
No; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Use coolers that minimize temperature
fluctuations, such as those with plastic strips in doorways; Benefits:
Facilitates maintaining proper food storage temperatures; School
districts: Yes; Federal agencies: No; State and local agencies:
No; Private sector: Yes.
Useful practices and suggestions: Install internal doors that have
pressurized air curtains and bug lights; Benefits: Reduces pest
infestation; School districts: No; Federal agencies: No;
State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Install computer-controlled
disinfectant dispensers on sinks; Benefits: Ensures proper strength of
disinfectants; School districts: No; Federal agencies: No;
State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Install hand sanitizer dispensers in
lunch room to allow quick hand washing for time-constrained students;
Benefits: Encourages proper personal hygiene; School districts: Yes;
Federal agencies: No; State and local agencies: No; Private
sector: No.
Useful practices and suggestions: Use a metal detector to identify
metal fragments in food; Benefits: Detects potentially dangerous
foreign objects in foods; School districts: Yes; Federal agencies:
No; State and local agencies: No; Private sector: No.
Useful practices and suggestions: Use temperature monitors that
withstand power outages; Benefits: Facilitates maintaining proper food
storage temperatures; School districts: No; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: 10. Recalls; Benefits: No;
School districts: No; Federal agencies: No; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Apply federal recall notification
procedures for donated foods to schools' commercial food purchases;
Benefits: Faster notification of all recalls, including commercial
recalls; School districts: Yes; Federal agencies: Yes; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Add additional state notification
points to federal notification system; Benefits: Faster notification
of recalls to other interested parties; School districts: No;
Federal agencies: Yes; State and local agencies: Yes; Private sector:
No.
Useful practices and suggestions: Implement state fax and e-mail system
to immediately send recall information to schools; Benefits: Faster
notification of recalls within states; School districts: No;
Federal agencies: No; State and local agencies: Yes; Private sector:
No.
Useful practices and suggestions: Register for direct e-mail
notification of USDA recalls; Benefits: Faster notification to schools
of recalls; School districts: Yes; Federal agencies: No; State and
local agencies: No; Private sector: No.
Useful practices and suggestions: Monitor recalls on federal agency and
other Web sites or newsletters; Benefits: Facilitates faster and
appropriate response to recalls; School districts: No; Federal
agencies: No; State and local agencies: No; Private sector:
Yes.
Useful practices and suggestions: Monitor supplier and distribution
information for effective communication during recalls; Benefits:
Facilitates faster and appropriate response to recalls; School
districts: No; Federal agencies: No; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: Develop state computerized electronic
purchasing system linked to local schools that is tied into FSIS recall
system; Benefits: Promotes notification to schools of recalls; School
districts: No; Federal agencies: Yes; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Develop memorandum of understanding
to allow FSIS to give suppliers' distribution data on recalled products
to states; Benefits: Facilitates faster notification of recalls;
School districts: No; Federal agencies: Yes; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: 11. Health inspections; Benefits:
No; School districts: No; Federal agencies: No; State
and local agencies: No; Private sector: No.
Useful practices and suggestions: Conduct health inspections of food
service operations two or more times annually; Benefits: Provides
enhanced health department oversight; School districts: Yes; Federal
agencies: No; State and local agencies: Yes; Private sector:
No.
Useful practices and suggestions: Use HACCP format for health
inspections of school and central production facilities; Benefits:
Ensures that critical food safety items are addressed during health
inspections; School districts: Yes; Federal agencies: No; State and
local agencies: Yes; Private sector: No.
Useful practices and suggestions: Require schools to immediately notify
school district's food service directors of health inspection results;
Benefits: Facilitates faster corrective actions; School districts:
Yes; Federal agencies: No; State and local agencies: No; Private
sector: No.
Useful practices and suggestions: Require larger schools to consult
with health departments and perform inspections and monitoring of food
safety management at least annually; Benefits: Provides health
department assistance and quality assurance in schools; School
districts: No; Federal agencies: No; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: 12. Traceback; Benefits: No;
School districts: No; Federal agencies: No; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Require vendors to be able to trace
all products back to suppliers; Benefits: Facilitates tracing of
contaminated foods; School districts: No; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: Require suppliers to deliver all
products to central or county warehouses where practical; Benefits:
Facilitates tracing of contaminated foods; School districts: Yes;
Federal agencies: No; State and local agencies: No; Private
sector: No.
Useful practices and suggestions: FOOD SECURITY[B]; Benefits: No;
School districts: No; Federal agencies: No; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Require background checks of food
service workers; Benefits: Lessens opportunities for intentional
contamination; School districts: Yes; Federal agencies: No; State
and local agencies: Yes; Private sector: Yes.
Useful practices and suggestions: Restrict visitor access to kitchens
and/or escort visitors in food preparation areas; Benefits: Lessens
opportunities for intentional contamination; School districts: Yes;
Federal agencies: Yes; State and local agencies: Yes; Private sector:
No.
Useful practices and suggestions: Secure food preparation and storage
areas when not in use; Benefits: Lessens opportunities for intentional
contamination; School districts: Yes; Federal agencies: Yes; State and
local agencies: No; Private sector: Yes.
Useful practices and suggestions: Require locks on all refrigerators,
freezers, and/or ice machines; Benefits: Lessens opportunities for
intentional contamination; School districts: Yes; Federal agencies:
Yes; State and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Purchase food from reputable
vendors; Benefits: Decreases likelihood of receiving adulterated
products; School districts: Yes; Federal agencies: Yes; State and
local agencies: Yes; Private sector: No.
Useful practices and suggestions: Verify the identity of food
deliverers; Benefits: Identifies unauthorized personnel; School
districts: Yes; Federal agencies: Yes; State and local agencies: No;
Private sector: Yes.
Useful practices and suggestions: Disseminate FDA security guidelines
to schools; Benefits: Promotes food security awareness; School
districts: No; Federal agencies: No; State and local
agencies: Yes; Private sector: No.
Useful practices and suggestions: Discuss security procedures with
suppliers; Benefits: Promotes food security awareness; School
districts: Yes; Federal agencies: Yes; State and local agencies: No;
Private sector: No.
Useful practices and suggestions: Select suppliers with security
statements ensuring a site security plan, security cameras, perimeter
guards, and employee identification; Benefits: Helps ensure that
suppliers use appropriate food security practices; School districts:
No; Federal agencies: Yes; State and local agencies: No;
Private sector: Yes.
Useful practices and suggestions: Inspect food shipments upon arrival;
Benefits: Provides opportunity to identify intentional contamination;
School districts: Yes; Federal agencies: Yes; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Require vendors to seal products in
tamper evident packaging; Benefits: Facilitates identification of
contaminated products; School districts: Yes; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: Complete a product evaluation form
for unacceptable products and possibly disqualify suppliers who exceed
a prescribed number; Benefits: Facilitates monitoring of food shipment
quality; School districts: Yes; Federal agencies: Yes; State and local
agencies: No; Private sector: No.
Useful practices and suggestions: Incorporate security measures in food
safety audits; Benefits: Focuses attention on food security; School
districts: No; Federal agencies: No; State and local
agencies: No; Private sector: Yes.
Useful practices and suggestions: Disseminate USDA's poster and flyer
on food security to schools; Benefits: Promotes food security
awareness; School districts: No; Federal agencies: Yes; State and
local agencies: No; Private sector: No.
Useful practices and suggestions: Disseminate AMS's paper on security
measures, such as sealing delivery trucks; Benefits: Promotes food
security awareness; School districts: No; Federal agencies: Yes;
State and local agencies: No; Private sector: No.
Useful practices and suggestions: Provide ongoing training in food
inventory controls, handling leftovers, receiving and storing food, and
packaging; Benefits: Promotes food security awareness; School
districts: Yes; Federal agencies: No; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Install facility access controls,
such as coded locks and entry intercoms at all food production areas;
Benefits: Lessens opportunities for intentional contamination; School
districts: Yes; Federal agencies: No; State and local agencies:
No; Private sector: No.
Useful practices and suggestions: Visit suppliers to check for security
measures and ensure that all products originate from known suppliers;
Benefits: Helps ensure that suppliers use appropriate food security
practices; School districts: No; Federal agencies: No; State
and local agencies: No; Private sector: Yes.
Useful practices and suggestions: Require background checks of
distributors' employees; Benefits: Lessens opportunities for
intentional contamination; School districts: Yes; Federal agencies:
No; State and local agencies: No; Private sector: No.
[End of table]
Source: GAO.
[A] Private sector sources we contacted are Chef America, Jack in the
Box, Sodexho, and Walt Disney World.
[B] Many food security practices may also be characterized as food
safety practices.
:
The following provides additional information on the supplier-related
food safety practices described in table 7. Three food supplier-related
safety practices could be valuable to school districts that have
resources to implement these practices and have commercial influence
over their suppliers. The first practice--selecting suppliers that
employ good food safety principles and procedures--was used by three
entities we contacted. For instance, Walt Disney World restaurants have
a Vendor Food Safety Program to screen new vendors and monitor existing
vendors. The company stated that it requires food safety evaluations of
its potential vendors, including E. coli O157:H7 testing of vendors'
high-risk foods, such as beef patties. In addition, the company reviews
the Sanitation Standard Operating Procedures, recall procedures, and
HACCP plans of the operating facilities of prospective suppliers.
Moreover, officials of the Veterans Health Administration told us that
they require their vendor to conduct safety inspections of all
warehouses and refrigerated trucks and to notify all Veterans Health
Administration facilities of any food recalls within 24 hours. In
addition, vendors are required to be able to trace all products back
through their suppliers to help track information during foodborne
outbreaks. Finally, according to Jack in the Box, all of its potential
suppliers are required to have HACCP-based food safety processes.
A second practice--requiring product safety specifications of
suppliers--was used by three entities we contacted. An official at Jack
in the Box told us that the company requires product specifications for
different types of food purchases depending on whether they are raw,
ready to eat, or to be heated prior to serving. The company's beef
safety program requires that potential suppliers meet certain criteria
for microbiological testing of meat samples for bacteria such as
coliform, E. coli O157:H7, Listeria monocytogenes, Salmonella, and
Staphylococcus aureus. In addition, suppliers are required to report
data on the age, bone weight, and number of foreign objects detected in
hamburger patty supplies. Similarly, Walt Disney World said that it has
a zero tolerance policy for E. coli O157:H7 and Salmonella in
children's beef patties. The company also trains smaller vendors on how
to furnish products that meet its requirements and requires suppliers
to inform it when any products from unapproved production sites are
substituted. According to officials at Sodexho, the company also has
product safety specifications and reviews the microbial guidelines of
its suppliers to ensure that products meet specifications.
A third practice--monitoring suppliers' performance to ensure
compliance with food safety requirements--was used by two entities we
contacted. Jack in the Box's monitoring program consists of auditing
all suppliers twice a year to examine product safety and quality,
employee safety practices, facilities, and equipment. The audits are
designed to evaluate specific products and the respective processes
used for their production. For example, hamburger patty samples are
regularly evaluated for compliance with physical and chemical
specifications. Suppliers must meet a minimum score to pass an audit.
In addition, suppliers are rated according to their performance in
these audits and other product quality evaluations. Those that receive
unsatisfactory ratings must demonstrate improvement or are no longer
allowed to supply the company. Sodexho officials told us that it also
has a supplier-monitoring program. The company's Food Safety Team
requires safety inspections of all food vendors by a third-party
auditor. Sodexho said that it provides its food suppliers with a list
of approved auditors. As an additional quality and safety measure, the
company said that it monitors the auditors' efforts by randomly
shadowing them during their vendor audits. The auditors examine
suppliers' management practices, safety capacity of suppliers'
manufacturing facilities, product compliance with regulatory
requirements and specifications, and effectiveness of suppliers'
quality control measures in ensuring consistent performance. Sodexho
officials told us they also conduct monthly testing of their products
for quality and safety and works with suppliers to correct defects. The
company also assigns staff to monitor supplier product information
during food recalls.
[End of section]
Appendix V: Comments from the Department of Health and Human Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Office of Inspector General:
Washington, D.C. 20201:
APR 2 1 2003:
Mr. Lawrence J. Dyckman Director, Natural Resources and Environment:
United States General Accounting Office Washington, D.C. 20548:
Dear Mr. Dyckman:
Enclosed are the department's comments on your draft report entitled,
"School Meal Programs: Few Instances of Foodborne Outbreaks Reported,
but Opportunities Exist to Enhance Outbreak Data and Food Safety
Practices." The comments represent the tentative position of the
department and are subject to reevaluation when the final version of
this report is received.
The department provided several technical comments directly to your
staff.
The department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Dennis J. Duquette:
Acting Principal Deputy Inspector General:
Signed by Dennis J. Duquette:
Enclosure:
The Office of Inspector General (OIG) is transmitting the department's
response to this draft report in our capacity as the department's
designated focal point and coordinator for General Accounting Office
reports. The OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
Comments of the Department of Health and Human Services to the General
Accounting Office's Draft Report, "School Meal Programs: Few Instances
of Foodborne Outbreaks Reported, but Opportunities Exist to Enhance
Outbreak Data and Food Safety Practices" (GAO-03-530):
The Department of Health and Human Services appreciates the opportunity
to comment on this draft report.
GAO Recommendation:
To improve nationwide data on the frequency and causes of foodborne
illness associated with the federal school meal programs, we recommend
that the Secretary of Health and Human Services require the Director of
the Centers for Disease Control and Prevention to revise the voluntary
foodborne outbreak reporting mechanism. Specifically, states should be
prompted to specify whether reported outbreaks involved foods served
through the federal school meal programs.
Department Response:
National surveillance for foodborne disease outbreaks was established
by the Centers for Disease Control and Prevention (CDC) in the 1960s to
collect information that is broadly useful for promoting public health.
The CDC has worked diligently in recent years to improve surveillance
for foodborne disease outbreaks, achieving a nearly 3-fold increase in
the number of outbreaks reported and converting reporting to a rapid
web-based system. The CDC is committed to maintaining and continually
improving surveillance for this important health outcome.
The current system for reporting is voluntary and depends on the
willingness and ability of local health officials to obtain and report
the requested information. Mindful of the demands that reporting places
on local officials, CDC has not made a practice of adding questions
that pertain only to specific settings (e.g., schools, prisons,
restaurants, private homes) or commodities (e.g., ground beef, romaine
lettuce, egg products).
However, the current GAO draft report indicates that many state health
officials are willing to collect and report additional information on
the source of items implicated in school-associated outbreaks. The CDC
is amenable to changing current data screens to capture this
information. To this end, CDC has already taken the following steps:
1) Requested from U.S. Department of Agriculture a definition for
"federal school meal" items so that state and local health officials
can properly categorize implicated food items:
2) Drafted questions for capturing this information:
3) Verified the feasibility of adding these questions to the
appropriate fields of the Electronic Foodborne Outbreaks Reporting
System.
Before implementation, additions to the data collection form will
require the approval of the Office of Management and Budget.
[End of section]
Appendix VI: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Lawrence J. Dyckman, (202) 512-5138
Maria C. Gobin, (202) 512-8418:
Acknowledgments:
In addition to the individuals named above, Samantha Gross,
Charles Hessler, Kurt Kershow, Suen-Yi Meng, and Doug Sloane made
significant contributions to this report. Important contributions were
also made by Aldo Benejam, Nancy Crothers, Curtis Groves, Judy Pagano,
and Kevin Tarmann.
FOOTNOTES
[1] Our analysis of CDC's school outbreak data includes outbreaks
associated with public and private elementary and high schools. CDC
school outbreak data also includes outbreaks associated with colleges
and universities. We excluded these outbreaks in order to have outbreak
data more relevant to our review.
[2] E. coli O157:H7 produces a potent toxin that damages the lining of
the intestines. Severe abdominal cramping and bloody diarrhea
characterize the resulting illness. About 2 to
7 percent of infections result in hemolytic uremic syndrome, which
destroys red blood cells and causes kidney failure. Hemolytic uremic
syndrome affects children more often than adults.
[3] GAO prepared an additional report describing nutrition in school
meals to support the reauthorization of the Richard B. Russell National
School Lunch Act. See U.S. General Accounting Office, School Lunch
Program: Efforts Needed to Improve Nutrition and Encourage Healthy
Eating, GAO-03-506 (Washington, D.C.: May 9, 2003).
[4] Because the outbreaks included in our survey are not a
representative sample, the survey results cannot be generalized.
[5] The School Breakfast Program is authorized by the Child Nutrition
Act of 1966, as amended.
[6] See U.S. General Accounting Office, Food Safety: CDC Is Working to
Address Limitations in Several of Its Foodborne Disease Surveillance
Systems, GAO-01-973 (Washington, D.C.: Sept. 7, 2001).
[7] Fatigue, poor appetite, fever, vomiting, and jaundice characterize
hepatitis A infections.
[8] Outbreaks included in the survey are not a representative sample,
and results from the survey are not projectable. Our survey did not
include outbreaks that involved less than
50 individuals. Furthermore, many outbreaks that occur in schools are
not reported, or the information provided to public health authorities
is incomplete.
[9] Bacillus cereus causes abdominal cramps and diarrhea that usually
last for 24 hours. Shigella causes more severe abdominal cramps and
diarrhea, usually lasting 5 to 7 days. Many strains of Shigella produce
a potent toxin that destroys tissue.
[10] Daniels, Nicholas A. et al. "Foodborne Disease Outbreaks in United
States Schools." The CDC study was published in the Pediatric
Infectious Disease Journal, Volume 21,
Number 7, July 2002.
[11] The differences between our results and CDC's results may be due
to the fact that our analysis is based on a much smaller sample and a
shorter time period than CDC used for its analysis.
[12] Fankhauser, Rebecca L., et al. "Epidemiologic and Molecular Trends
of 'Norwalk-like Viruses' Associated with Outbreaks of Gastroenteritis
in the United States." The CDC study was published in the Journal of
Infectious Diseases, Volume 186, July 2002.
[13] Food and Drug Administration, Report of the FDA Retail Food
Program Database of Foodborne Illness Risk Factors, August 2000.
[14] The Food Code represents FDA's guidance for a uniform system of
regulation for ensuring that the foods sold or offered for human
consumption in restaurants, grocery stores, schools, and nursing homes
are safe, properly protected, and honestly presented.
[15] FSIS is the public health regulatory unit within USDA that
regulates all meat, poultry, and egg products sold in interstate
commerce.
[16] Food manager certification requirements for Pennsylvania and
Indiana become mandatory in July 2003 and December 2004, respectively.
[17] "ServSafe" includes training on topics such as foodborne
illnesses; microbial contaminants; safe food handling, purchasing and
receiving safe food, safe food storage, safe food preparation and
service; and food safety regulation and standards.
[18] The Conference for Food Protection is a nonprofit advocacy group
made up of food industry, government, academia, and consumer
organizations that addresses food safety issues and certifies food
safety training programs.
[19] The Institute is a congressionally established FNS-funded resource
center at the University of Mississippi dedicated to continuous
improvement of child nutrition programs. Its "Serving It Safe" course
includes training on topics such as food safety, preventing foodborne
illness, microorganisms, and sanitary food service.
[20] HACCP is well known in the U.S. food processing industry. As part
of their food safety oversight responsibilities, USDA and FDA require
meat, poultry, seafood, and fruit and vegetable juice processors to use
HACCP to limit the spread of foodborne disease-causing pathogens. Food
establishments are required to adopt monitoring procedures, corrective
actions, verification procedures, and record-keeping procedures.
[21] Some school districts prepare or use food safety training and
other materials in languages other than English. For example, officials
from Montgomery County, Maryland's Food and Nutrition Service Division,
told us that they offer food safety training in English, Spanish, and
Chinese. Also, FNS is expanding its efforts to provide school food
safety-related materials in Spanish.
[22] Irradiation involves exposing food briefly to radiant energy (such
as gamma rays or high-energy electrons) to reduce or eliminated
microorganisms that can contaminate food.
[23] USDA, School Food Purchase Study: Final Report, (Washington, D.C.:
Oct. 1998).
[24] Campylobacter jejuni is a bacterium that causes diarrhea and may
cause fever, abdominal pain, nausea, headache, and muscle pain.
Infection is most common in children under 5 and young adults.
[25] FSIS issued final regulations, effective in February 2000, that
specified appropriate irradiation dosage levels.
[26] See U.S. General Accounting Office, Food Irradiation: Available
Research Indicates That Benefits Outweigh Risks, GAO/RCED-00-217
(Washington, D.C.: Aug. 24, 2000).
[27] See U.S. General Accounting Office, School Meal Programs: Few
Outbreaks of Foodborne Illness Reported, GAO/RCED-00-53 (Washington,
D.C.: Feb. 22, 2000).
[28] FSIS regulations require that raw ground beef be sampled on
consecutive days of production over a given period of time.
[29] See U.S. General Accounting Office, School Meals Programs: Revenue
and Expense Information from Selected States, GAO-03-569 (Washington,
D.C.: May 9, 2003).
[30] See U.S. General Accounting Office, Food-Processing Security:
Voluntary Efforts Are Under Way, but Federal Agencies Cannot Fully
Assess Their Implementation, GAO-03-342 (Washington, D.C.: Feb. 14,
2003).
[31] USDA, FSIS Security Guidelines for Food Processors (Washington,
D.C.: Apr. 2002).
[32] To simplify the analysis and presentation of outbreak causes, we
defined "improper food preparation and handling practices" as including
survey responses of improper food storage, improper food handling,
inadequate cooking, poor food worker hygiene, ill food workers
preparing food, improper hot-holding of foods, and improper cooling of
foods.
[33] The following limitations in CDC data make assessment of food
safety in the federal school meal programs difficult: foodborne illness
outbreaks are generally underreported, outbreak reporting practices
vary among states because reporting is optional, and CDC's category of
school does not distinguish separately federal school meals and also
includes colleges and universities.
[34] We also contacted school districts in Florida and North Carolina
to discuss food safety practices.
[35] Kids First is a public/private partnership to improve health,
nutrition, and education in Rhode Island school systems.
[36] Marler Clark is a law firm with extensive experience in
representing victims of foodborne illness.
[37] Safe Tables Our Priority, a nonprofit organization, is devoted to
assisting victims of foodborne illnesses, and providing public
education and policy advocacy in safe food and public health.
[38] Sodexho, a food service management company, provides food and
facilities management services to over 400 school districts.
[39] Outbreaks in Ohio increased from 15 outbreaks (1982-1984) to 287
outbreaks (1997-1999). Outbreaks in New York decreased from 658
outbreaks (1982-1984) to 204 outbreaks (1997-1999).
[40] See U.S. General Accounting Office, School Meals Programs: Revenue
and Expense Information from Selected States, GAO-03-569 (Washington,
D.C.: May 9, 2003).
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