ADVANCEMENT OF THE PRACTICE
Open Access
GUEST EDITORIAL
Beyond Inspections: Using Foodborne Outbreak Data to Drive Prevention
John J. (Jack) Guzewich, MPH
A recent article in Morbidity and Mor- tality Weekly Report provides crucial insight into the contributing factors for foodborne disease outbreaks in the U.S. (Holst et al., 2025). The article includes insightful comparisons between foodborne outbreaks before the COVID-19 pandemic and foodborne outbreaks during the pan- demic. This article should not be seen as just an interesting read to file away—it should be seen as a challenge to our food safety systems. Some people might view foodborne out- break investigations as a need to conduct inspections and identify regulatory violations for enforcement actions. While enforcement actions could be called for in some cases, we should see these investigations as an oppor- tunity to identify actions that can prevent future outbreaks, and not just in one loca- tion. Further, by compiling the findings of many investigations, we can identify patterns that can be addressed more broadly. From 2014 to 2022, 6,618 foodborne out- breaks from the National Outbreak Report- ing System (NORS) were analyzed (Centers for Disease Control and Prevention [CDC], 2024a; Holst et al., 2025). More than 57% of these outbreaks reported no contributing factors and some reports included factors that are not plausible for the agent, which suggests the need for training of the profes- sionals who conduct environmental assess- ments. The Centers for Disease Control and Prevention (CDC), along with the Tennessee Center of Excellence, created three learning labs to equip environmental health special- ists and public health sta with the skills needed for identifying contributing factors and root causes of foodborne illness out- Identifying and Reporting Contributing Factors
breaks (Integrated Food Safety Centers of Excellence, 2025; Figure 1). These learning labs, based on real outbreaks, are interactive and provide helpful outbreak investigation resources. The materials, which include facilitator guides, are available online for in-person and online delivery methods. These foodborne outbreak investigations should not only identify contributing fac- tors but also the root causes of these factors. Knowledge of the contributing factors and their root causes points to food safety preven- tion priorities for industry and government. Food regulatory agencies and industry should develop metrics that can demonstrate that the frequency of contributing factors and root causes identified during routine inspections are declining. This measure is the true indica- tor of the success of a food safety program, not the number of inspections conducted. Since root causes are not reported in the article, this editorial can only provide examples that relate to the reported contributing factors. Using Outbreak Data to Determine Metrics For bacterial foodborne outbreaks, the con- tributing factor of allowing foods to remain out of temperature control for a prolonged period during preparation had a reported frequency of 28–30%. A goal could be set to reduce the frequency of this factor to 20% within 3 years. With that goal set, we can then compare the frequency of this factor with the frequency of inspectional violations being cited that relate to the factor. The baseline is the current fre- quency of the violations, and the metric should show the reduction each year from whatever the initial frequency was. For viral outbreaks, the three most fre- quently reported contributing factors were contamination from an infectious food worker through:
1.bare-hand contact with food, 2.unknown hand contact; and 3.glove-hand contact with food.
The reported frequency for the contribut- ing factors ranged from 8.9% to 12.6%. A goal could be to reduce the frequency of occur- rence to 5%. The inspectional metrics for all three factors are to reduce the frequency of ill workers preparing food and to reduce worker contamination of food, gloves, and food contact surfaces. Inspectional findings should demonstrate the reduced frequency of violations related to ill workers and hand contact-related violations. Again, it is impor- tant to emphasize that the baseline is the cur- rent frequency of the violations, and the met- ric should show the reduction each year from whatever the initial frequency was. The Environmental Health Specialists Network (EHS-Net) from CDC (2024b) developed a plan for retail establishments to manage sick workers (Figure 2). The guide provides the tools to help retail establish- ments make a plan to keep sick workers home instead of coming to work while ill with a foodborne illness. The guide can be a great tool in reducing contributing factors related to ill food workers. Contamination Before Arriving at Retail Settings What metrics can we use to address the pri- ority contributing factors for food contamina- tion? Food contaminated by an animal or envi- ronmental source before arriving at the point of final preparation was the most frequently reported contributing factor. For food source issues, retail food regulatory agencies need to work with partner regulatory agencies and industry to ensure that programs are in place to reduce the number of food source-related out- breaks from approximately 42% of outbreaks to a hypothetical goal of 30% of outbreaks over
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Volume 87 • Number 10
https://doi.org/10.70387/001c.140443
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