The COVID-19 pandemic that first hit the United States in 2020 has been the largest public health crisis in more than 100 years, leading to millions of deaths globally and altering the global economy for years to come. As just one example of the far-reaching negative impacts of this virus, it has devastated the restaurant and foodservice industry in the United States and has changed the food industry’s global supply chain for years to come. Restaurant and foodservice loss of sales alone was reported by the National Restaurant Association to surpass $185 billion between March and August of 2020.1 Now as the pandemic has entered its second full year, there is hope that pharmaceutical interventions (i.e., vaccines and antiviral drugs) will significantly reduce the impact the pandemic has on lives and the economy.
Non-pharmaceutical interventions (NPIs) to control the spread of the virus were quickly implemented at the onset of the pandemic and are now widely used across the United States. NPIs include control measures such as adoption of masks and other facial coverings, practicing social distancing, emphasizing the importance of hand hygiene, and adoption of enhanced sanitation protocols. In general, hygiene and sanitation practices and procedures have been elevated in all businesses including the food industry. Those who did not have procedures and plans in place quickly developed new Standard Operating Procedures (SOPs), adopting new practices and products to help control the spread of the SARS-CoV-2 in their environments. There is significant evidence that use of NPIs to prevent the transmission of the respiratory virus SARS-CoV-2 from person to person has reduced the number of illnesses and deaths from this virus during the pandemic.2 Likewise, these NPIs have been suggested to also reduce the incidence of influenza in the United States and other countries,3 as significant drops in illnesses and deaths in the United States have been observed during the pandemic.
Reduction in certain enteric disease outbreaks (where spread occurs via a fecal-oral route of transmission) has been noted as well. For instance, outbreaks of norovirus, the most common cause of foodborne illness in the United States, declined by over 80% between April and July of 2020 as compared to the same date range in previous years, according to data reported to the National Outbreak Reporting System (NORS) at the CDC.4 A recent study to better understand this drastic decline also observed norovirus outbreaks in this time period in 2020 to be 61% smaller compared to prior years.5 Although underreporting of norovirus outbreaks was initially suspected to be the cause of this decline, investigators determined that the more likely scenario was adoption of NPIs being used for SARS-CoV-2 prevention during this time period had an added effect of assisting in controlling norovirus outbreaks.
Adopting expansive COVID-19 NPIs has clear public health benefits beyond controlling COVID-19 alone. It’s worth taking a deeper look at some of the specific control measures to better understand just how these have an added benefit of helping to control foodborne illnesses, such as norovirus. While adoption of these control measures is often considered a temporary guidance, establishments should consider implementing many of these as long-term best practices and SOPs in order to enhance their overall food safety plan.
Here are several specific COVID-19 NPIs that an establishment can adopt to enhance their food safety plan and reduce their risk of causing a foodborne illness outbreak:
- Keeping sick individuals out of an establishment – As a respiratory virus, SARS-CoV-2 can spread from person to person very efficiently. Because of this, many NPIs focus on reducing the potential for person-to-person spread to occur. Control measures such as social distancing, capacity restrictions, and preventing sick individuals from entering an establishment through wellness checks all seek to reduce the chances of person-to-person spread. Adoption of sick leave policies and employee wellness screens to ensure employees are not reporting to work while sick with foodborne illness (such as norovirus) will reduce the risk of a facility causing a foodborne illness outbreak. In fact, in 2017, a risk assessment study by the United States FDA found that excluding employees from reporting to work when they are ill with norovirus was one of the most effective ways of reducing a restaurant’s risk for causing a norovirus outbreak.6
- Emphasizing frequent and proper hand hygiene – Some have remarked that COVID-19 has caused society to enter a “Golden Age” of handwashing. While this may have been said in jest, it is important to remind ourselves of the clear public health benefits of hand hygiene practices. With these benefits in mind, many NPIs rooted in hand hygiene have been adopted as temporary guidance policies, including mandating frequent handwashing with soap and water for 20 seconds or longer for employees, providing handwash stations with soap and water for guests and employees, and providing alcohol-based hand sanitizers to guests and employees when soap and water are not available. In the FDA study referenced above, the same researchers also identified proper handwashing with soap and water as a major way of reducing a facility’s risk for causing a norovirus outbreak.6 With this in mind, establishments should emphasize frequent and proper hand hygiene as a major aspect of their food safety plan.
- Elevating sanitation practices, including touchpoint disinfection – There are many COVID-19-related temporary guidance policies where enhanced touchpoint disinfection practices are adopted as NPIs. Examples include frequent disinfection of restrooms, door handles/entrances, and shopping carts; requiring increased frequency of disinfection (e.g., every 2 hours); and adoption of EPA-approved products. Establishments should continue to adhere to these elevated practices even after the pandemic is over since they have direct carryover to controlling foodborne illnesses, especially norovirus. Norovirus can persist on surfaces for weeks if not properly cleaned and disinfected. In fact, there are many examples of norovirus outbreaks where the cause was ultimately determined to be a contaminated surface or touchpoint that was not cleaned and disinfected properly. Product choice matters as well – when possible, choose products with short kill claims for the organisms of interest for your establishment. By keeping contact times short, compliance with enhanced sanitation protocols can increase, which helps reduce risk of an outbreak within a facility. Turnkey programs such as the "NOROVIRUS HOT SPOT™ + COVID-19 Program" also exist, where a disinfectant is combined with a set of procedures and SOPs that a facility can quickly adopt and integrate into their food safety plan.
Viruses like norovirus are often first transmitted in retail food and foodservice establishments via transmission from employees’ hands to environmental surfaces like restroom door handles or handwash sink faucet handles.7 The viruses are then transmitted to other employees unknowingly when they touch these common surfaces, which then leads to cross-contamination of food, even in situations where the food handler is wearing gloves.8 Therefore, the establishment must include in its SOPs to train and screen employees for illness in an attempt to prevent this first transmission event. Likewise, SARS-CoV-2 can be transmitted to high-touch surfaces and hands where it can lead to infection, although this risk is considered much lower than aerosol transmission of the virus.9 Thus, the NPIs of hand and surface cleaning and sanitation are important to the prevention of both SARS-CoV-2 and norovirus transmission. Some have stated that because SARS-CoV-2 is not significantly transmitted from surfaces to persons, employees in the food industry do not need to focus on the cleaning and disinfection of high-touch surfaces. However, many foodborne diseases (especially norovirus) can be transmitted from surfaces to persons and then to hands, where cross-contamination of food can occur. It is likely that the use of these controls is a contributing factor to the decline in norovirus outbreaks in the United States.
The best means to reduce the risk of foodborne illnesses in a retail food or foodservice establishment is through establishing a Hazard Analysis Critical Control Point (HACCP)-based Food Safety Management System (FSMS), where all hazards are identified and controls established, employees are trained on the SOPs and managers are trained to manage them, the controls are monitored daily, and when a control is not working or absent, it is corrected in real time to significantly reduce risk of foodborne illness transmission.10 A FSMS should be based on the processes used to source, receive, and prepare foods based on a business’s menu, including a well-developed cleaning and sanitation program, and used daily to ensure the business can achieve Active Managerial Control of all risk factors that lead to foodborne illnesses (see King, 202011 and The FDA Food Code Annex 412).
Breaking the chain of human infectious disease transmission has always been a challenge, especially when there is no vaccine to prevent a disease like norovirus or SARS-CoV-2 (until recently). The challenge is even greater when the infectious disease is a respiratory disease spread simply in the air and a large percentage of transmission is from asymptomatic infected persons. The only means to prevent both infectious diseases must be by using multiple controls (like speed bumps on a road used to slow down traffic and prevent traffic accidents) to reduce the risk of exposure and infection. Retail food and foodservice establishments that master the incorporation of these controls into their facility’s overall safety plan will be positioned for success in the future, long after COVID-19 has become a memory.
Knowing an enemy is the first step toward defeating it – which is why building an understanding of pathogens is paramount to any prevention strategy. Learn more about norovirus, as well as prevention solutions, with the latest research and insights, by signing up to download this new bulletin.
To find out more about the "NOROVIRUS HOT SPOT™ + COVID-19 Program" from Active Food Safety, in partnership with the PURELL® brand, please visit the portal here.