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From: Food Quality & Safety magazine, October/November 2007

Break the Chain of Outbreaks

Keep the virus in the restrooms and away from ready-to-eat foods

by Jim Mann

Public restrooms and home bathrooms are the dominant sources of virus, and the primary transmission route is fecal-hand-oral. Today’s restaurateurs risk their livelihoods with anything less than an all-out aggressive attack. The port-of-entry to restaurants for norovirus and hepatitis A is split between the back door and the front door. The battleground covers nearly the whole footprint of the food service establishment. Interventions are needed at key viral intersections, with special attention given to the primary onsite viral harbor, the restroom.

Through the back door enters the ill employee and, through the front, the ill customer. Between these two doors are shared spaces we call the Xchange, where pathogens are regularly traded in patterns of unplanned contact and contamination (see Figure 1, p. 44).

Employees with symptoms can be screened out using the ill employee policy. Those without symptoms, the asymptomatic carriers, cannot be identified. They are free to work, prepare and serve all the foods handled by their healthy counterparts. The ready-to-eat (RTE) category of food becomes a particularly high risk one.

Thoroughly Assess Risk

Keeping pathogens in the restroom and off the menu—and the owners out of court—starts with a thorough assessment of the risks and the current barriers intended to keep the virus from intersecting with the food flow. Perform an in-depth review of cleaning methods and the frequency of restroom protocols carried out both by staff and contracted services. Hand hygiene and surface cleanliness are critical interventions in the restrooms, the kitchen, and the entire customer-service area.

The virus is clearly the primary predator on a long list of pathogens putting restaurants at risk. Most viruses start with invisible particles of fecal matter. For years the focus has been on bacteria and the kitchen’s food-sourced pathogens. But viruses are much smaller, generally more virulent, and harder to control than bacteria. As the enemy changes, so must hand washing standards and practices.

Operators are responding by specifying more integrated designs, with fewer access and transfer points and easier-to-clean surfaces. It is not surprising when you look at the overwhelming statistics on norovirus and hepatitis A that we see hand washing as the focus. The Centers for Disease Control and Prevention (CDC) point out that “hand washing is the single most important means of preventing the spread of infection.”

Poor hand hygiene is the virus’ best friend. It’s all about escape, survival, and the recurring fecal-hand-oral cycle. Hands are the documented bridge for the migrating virus, but holes in the operator’s hand hygiene intervention system are often just as invisible as the determined enemy. A well-disciplined third party audit can help discover risks otherwise masked by the rush of the daily routine.

The Back Door Virus

The ill employee policy is the first line of defense at the back door. Employers have made major strides in improving implementation of sick worker exclusion policies. A rigorous, aggressive, and highly visible hand washing program is the required backup response to deal with asymptomatic workers. A vaccine program, which has been used effectively in Las Vegas, can take the hepatitis A virus off the table and should be considered, especially when operating or building in endemic areas.

Creating systems has been a hallmark of restaurant progress. A system integrates all the detail into daily actions. While systems provide a basis for control and continuous improvement, they have eluded the area of hand washing. Most operators boast of their hand washing training, beaming at the question of certified managers, but go silent when asked about their hand washing system. Without a system, what do quality assurance and third-party auditors monitor? Where is the customary documentation for management review? What are the standards?

Building an enduring system starts with oper ations, quality assurance, and risk management convening to put the known risks of poor hand hygiene into the context of a particular business: its menu, its facility, its customers, its purchasing policies, and its managers’ effectiveness in motivating and controlling the staff. The operation’s tolerance for risk should be included in this baseline discussion.

This temporary team starts converting the staff’s food handling practices into a safe level of hand washing: the number of hand washes per shift that will likely keep us out of the courtroom. This standard can be monitored simply by placing a digital counter in the soap dispenser. Local managers can now add this line to their quality assurance/operational reporting, highlighting dangerous deviations.

Good hand hygiene behaviors are best achieved using equipment and products that make it easier for the staff to do the right thing consistently. A convenient, touch-free hand hygiene unit is a good example. Added to the hygienic factor are time and water savings, which normally cover this investment in the first year.

Quick access to fused-bristle nailbrushes and well-fitted National Sanitation Foundation-approved gloves will improve compliance. Ergonomic considerations help define better equipment and supplies. Quality builds reliability, worker confidence, and compliance.

Staff training is an important factor now that standards are in place. The effectiveness and sustainability of training will be multiplied by the use of safe level standards in combination with a monitoring system. After all, what gets measured gets done!

The Front Door Virus

While keeping the ill employee off the food service premises continues to be difficult, keeping ill customers at bay is impossible. Just ask the cruise industry and their health inspectors, the CDC’s Vessel Sanitation Program. It is passengers and their microbes that are turning ships back to port for costly decontaminations.

Customers are increasingly protected by operator leaders who are placing hand sanitizers at business entrances, in play areas, and at the heads of serving lines. Recent research indicates increased norovirus and hepatitis A effectiveness for “synergized” alcohol hand sanitizers, opening up opportunities to further reduce operator risk.

The Xchange Area Virus

Restrooms are critical harbors for viruses that arrive through both the front and rear doors. Almost all viral outbreaks start in a restroom, whether it is in a home or away from home, with—of course—a fecal-hand-oral pathway. Customers returning from restrooms to tables can ignite a blaze of contamination as servers and bussers cross-contaminate with innocent touches of service.

Consider these common situations. One: Mom is thrilled because the family is dining out today. Junior is coming down with something, but the symptoms aren’t severe at the moment. Let’s go!

Two: A person driving along endures a sudden and powerful stomach cramp. It could be explosive. Where is the nearest port to weather the oncoming storm? “Here’s a restaurant. Thank heavens! Just in time!” So who makes more visits to and spends the most time in the restroom—the sick or the healthy?

Cleaner Surfaces, Cleaner Hands, Safer Food

Restroom cleanliness is increasingly affecting the consumer’s choice in away-from-home dining. Restrooms must be welcoming and comfortable, as suggested by the label “comfort station.” User comfort is a complex but instant perception formed by visual cues and the fresh air of cleanliness.

Shortcomings in a restroom protection system can best be overcome with more control and monitoring of cleaning methods and their frequency. Proper use of a quality-minded service company is often an important part of the solution. Periodic measurement and reporting of surface cleanliness help to keep the focus on this important environment.

Cleanliness monitoring can range from simple black light methods that expose the areas missed by the cleaning crew to more sophisticated adenosine triphosphate measurement devices designed to indicate the presence of organic contamination. Cleaner surfaces are a meaningful virus intervention and result in cleaner hands and safer food.

Keep Hot Air Dryers Out

Before specifying hot air dryers for restrooms, consider why they are no longer a part of the professional kitchen. They are too slow, too noisy, and do not offer the documented cleaning that results from the friction involved in using a paper towel. This is clearly a place for a touch-free automatic paper towel dispenser.

Wet restroom floors are a frequent source of slip-fall legal cases in restaurants. A common cause is a hand washer with clean, dripping hands looking for the air dryer. The dryer is often positioned away from the sink so that its long drying time doesn’t result in a traffic jam at the sink.

The final step in the operator’s line of defense involves the question, “Where should hand washing and hand sanitizer stations be located?” Use the viral flow chart as an analytic tool, and apply your findings specifically to your facility, menu, and customer base (See “Hand Sink Location,” p. 43).

The good news is that, by basing your hand hygiene standards on viruses, you are eliminating bacteria at the same time, without adding any interventions. An integrated system addressing all three classes of virus—front, back, and Xchange areas—pays big dividends. One initial payback is reduced absenteeism; your integrated viral control system also keeps respiratory bugs at bay, resulting in fewer colds and flu attacks.

Mann is executive director and chief scientific officer at HandwashingForLife. Reach him at (800)-446-3628. For more details, visit



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