The Centers for Disease Control and Prevention (CDC) estimates there are 20 million cases of norovirus every year resulting in 70,000 hospitalizations and 800 deaths. The symptoms are vomiting, diarrhea, nausea and stomach cramping. Most people will be sick for only a couple of days, but they may be contagious for up to 3 days. Typically, people become exposed to norovirus from contaminated food or water, but this can spread to others from close personal contact. So if a ship serves contaminated food resulting in a couple dozen norovirus cases, this can spread across the ship, bringing the number of cases into the hundreds. 

Lately, norovirus has been cruising with a vengeance. In early February, the Ruby Princess and Crown Princess both had outbreaks involving nearly 500 people. A few days later, the Crown Princess again returned to port with 364 sick passengers and 32 sick crew. More recently, the Celebrity Cruises Celebrity Silhouette reported to St. Maarten with 185 cases of suspected norovirus aboard the ship.

Norovirus is a frequent traveller on cruises. From Jan. 1, 2003 to Feb. 16, 2012, there have been 25,338 reported cases of cruise ship illnesses. Taking into consideration all the cruise ships in operation, this might seem like an insignificant number. But I would hate to shell out thousands of dollars for a cruise only to spend it buried in the toilet with no escape. It appears the cruise ship industry has a problem preventing and containing illness on their vessels.

Why Is Norovirus So Prolific on Cruises?

Is it the romantic scenes, exotic stops or endless entertainment? Actually, It must be the intimate onboard conditions. A combination of perfect temperatures, confined spaces and 3,000 incubation vessels (people) is a dream situation for norovirus. It spreads quite freely between people in close quarters. Norovirus is very persistent and can be present in the air after someone has vomited. And on a ship, once you have a couple hundred infected people repeatedly vomiting all over the place, there really is little hope for escape. 

When norovirus was first diagnosed on cruise ships, quaternary ammonia was a common way to sanitize the ships. It was after the same ships were having repeated outbreaks even after sanitizing that investigators realized quaternary sanitizers were widely ineffective against the pathogen. Chlorine-based sanitizers are now found to be the best at controlling norovirus. Check out the EPA list of products effective against norovirus. It’s extremely important to sanitize every inch of an affected area to adequately eliminate norovirus.

CDC Oversight?

The cruise lines point to a rigorous inspection criteria implemented by the CDC to ensure everything is being done to prevent illness on their vessels. The program is called the Vessel Sanitation Program. It looks like an extensive and vigorous inspection program. The scores and inspections are available for public review. There is a list of all the ships that have scored 100, the best possible score. Sounds great, right? Well, after taking a closer look, all 3 ships mentioned above had perfect scores on their last inspections. But if they had perfect scores and still had an outbreak, is the program really working, or is norovirus impossible to defend against?

Upon further investigation, I found the scores were quite misleading. All 3 ships had several violations but didn’t receive any points deducted from their scores. Many of the violations directly related to spreading illness. Here is what was found:

Crown Princess

Inspection date: 11/19/11

Violations: 33 total including temperature-abused food, and “no procedures in the Outbreak Prevention and Response Plan for returning the vessel to normal operating conditions after an outbreak,” “no disinfectant in the diaper changing station,” and “rat guards were not placed correctly around the rope while the ship was docked, which could allow rodents to enter the ship.”

Ruby Princess

Inspection date: 11/10/11

Violations: 27 total including sick crew members not reporting to the medical center in a timely manner, no established washing procedure for ice buckets and no way of assuring each ice bucket is returned to the same cabin from where it was removed, no procedure in the Outbreak Prevention and Response Plan for notifying embarking passengers following an outbreak voyage, improper disinfection procedure for cleaning up a fecal accident, and staff not monitoring recreational water facilities for combined chlorine residual (that kills bacteria in the water).

Celebrity Silhouette

Inspection date: 12/18/11

Violations: 28 total including a cleaning employee working while sick, no serving utensils for apples in several buffet lines (which contributes to cross-contamination for patrons), and the Outbreak Prevention and Response Plan did not include procedures for returning the vessel to normal operating conditions after an outbreak.

These don’t look like perfect inspections to me. If a ship can get 2 dozen violations and still receive a perfect score, where’s the incentive? I know many of you reading this love cruises and will continue to go on them. That’s great, but next time, do your homework.

Check out cruise ship inspections posted by the CDC, but don’t pay so much attention to the scores — read the reports. Next, visit Cruise Ship Norovirus, a very informative and up-to-date website on cruise ship illnesses. 

If you happen to be reading this while on a cruise, don’t panic. Wash your hands frequently and stay out of the path of sick passengers. If you’re already sick, stay in your room so you don’t infect others and drink lots of fluids. Norovirus can strike anywhere and anytime. Be prepared. 

What do you think? Is the cruise ship industry doing enough to prevent illness, or is it inevitable that every year they will be plagued with outbreaks? 

———————-

Dennis Keith is founder and CEO of the consulting company Respro Food Safety Professionals. ‘Cruisin’ for a Bruisin’: Norovirus Rules the High Seas” first appeared on his Utah Food Safety Blog March 3, 2012.

Sprouts and Illness

Sprouts have a long history with foodborne illness. Racking up 55 outbreaks in 14 years, sickening 15,000 and killing dozens makes them quite formidable. However, there are also thousands of other restaurants serving raw sprouts every day that have never been implicated in an outbreak. As a food safety consultant, I like to err on the side of caution and reduce liability for my clients. Reducing liability definitely means not serving sprouts raw. 

How Do Sprouts Keep Getting Contaminated?

Contamination usually starts with the seeds. According to the Centers for Disease Control and Prevention, the seeds can become contaminated in the field from agricultural water, improperly composted manure, contaminated soil or from roaming animals. As the contaminated seeds grow, the bacteria can grow to harmful levels by the time the sprouts are harvested. If bacteria are present in the seeds instead of on them, they can’t be cleaned off like other produce and fruit. This makes it difficult or even impossible for some contaminated sprouts to be served safe. Since 1999, the FDA has provided guidelines to the sprout-grower industry on safe ways to grow sprouts. Apparently, more work needs to be done.

The CDC doesn’t think certain people should even take the chance. They advise that children, older adults, pregnant women and people with weakened immune systems should avoid eating raw sprouts of any kind, including alfalfa, clover, radish and mung bean sprouts.

Can Sprouts Be Grown Free of Bacteria?

Ask the  Sproutpeople. They insist that sprouts are one of the safest foods on the planet. They may have a point since Certified Organic Growers only use manure free of harmful bacteria. This may prevent the seeds from becoming contaminated in the field. However, they may need to update their data since it’s missing 13 years of outbreak information, including the 2010 sprout outbreak linked to Tiny Greens, a sprout grower Certified by the Global Organic Alliance.

There is one final part of this argument that concerns me. Jimmy John’s has spent the last 4 years attempting to serve safe sprouts, and yet has been at the center of  five alleged outbreaks since 2008. Jason’s Deli, Erbert & Gerbert and Walmart didn’t even want to try any more. If these large corporations don’t seem to have the resources to ensure they could serve raw sprouts safely, then how are smaller chains and local food establishments going to do it?

If restaurants want to keep raw sprouts on the menu they should do the math. If the menu items containing raw sprouts are hot sellers, they may choose to keep them, but if only a few are sold, is it really worth the risk? 

As for why Jimmy John’s made the decision: “Jimmy decided he was tired of the negative press from it and he thinks sprouts aren’t necessary for Jimmy John’s to rock,” franchise owner Will Aubuchon told the Daily Express in Kirksville, MO. I’m sure it’s more than negative press that’s keeping sick Jimmy John’s customers from coming back.

————————

Dennis Keith is founder and CEO of the consulting company Respro Food Safety Professionals. 

Many people took notice of the impact of foodborne illness when headlines reported on the Jack in the Box outbreak of 1993. That outbreak resulted in 750 children poisoned with 4 dying. In this case, E. coli went undetected and slipped past all controls to find its way into the hands and stomachs of the victims. In author Jeff Benedict’s book “Poisoned,” the Jack in the Box executives claimed they had no idea they were serving food that could kill kids. Some of the same causes for that outbreak are still happening today. Unfortunately, it seems that some restaurant organizations need to have a food safety crisis with real measurable casualties before they clean up their act and put real sustained controls in place. 

One possible reason for an increase in foodborne illness outbreaks is that some people think the USDA, FDA and health departments offer enough regulation and provide adequate protection against foodborne illness. However, this is a false sense of security. The USDA is getting ready to cut 259 jobs. It’s unlikely that this will be beneficial in protecting our food supply. With budgets diminishing and health departments consolidating their services, health departments are developing new ways to reduce their regulatory oversight of the food service industry. The city of Chicago and the Maricopa County Health Department have already put new plans in place to allow responsible operators to police themselves. If this trend continues, public health officials will only have time to track down these emerging threats rather than trying to prevent them. 

To further complicate the problem, food manufacturers are hiring third-party auditors to prove their food is safe, only to have that practice backfire with the recent cantaloupe and peanut outbreaks. In those cases, the auditors received harsh criticism for not identifying problems, and they gave exceptional scores to the manufacturers that hired them. Third-party auditors are useful tools only when they identify all the food safety deficiencies.

Without more oversight of food safety practices, we’ll continue to see headlines such as these:

68 Sickened at ‘Mexican-style’ Restaurants in 10 States

112 people sick from sprouts contaminated with Salmonella (linked to alfalfa sprouts served at Jimmy John’s restaurants)

146 people infected with norovirus may have become sick after eating at Bob Chinn’s Crab House

So, with many restaurants failing to understand that there is a war on foodborne illness happening, who is left to fight? For decades it has been left to local health departments. But we cannot solely rely on the public health sector to set policy and management practices for the restaurant industry. The time has come for the industry as a whole to step up and join the fight. Restaurant owners and operators should hold each other to a higher standard by educating themselves about foodborne illness and striving to serve safe food to the public.

Many in the industry are already taking responsibility. There are plenty of food-safety-conscious owners and operators who are implementing policies and best practices for preventing foodborne illness and promoting food safety in their organizations. This can be expensive, but there really is no comparison to the cost of paying damages from an outbreak. Jeff Benedict reported that it cost Jack in the Box $98 million in damages. Their insurance barely paid it all. How many restaurant organizations out there have a $100 million insurance policy? For many restaurants, having an outbreak spells bankruptcy. Jack in the Box learned its lesson the hard way. As a result, the company hired food safety expert David Theno and revamped its entire food safety program. 

Restaurant owners and managers need to understand that they are potentially handling contaminated product every day. This means it’s essential to control all factors that can lead to foodborne illness.

———————— 

Dennis Keith is founder and CEO of the consulting company Respro Food Safety Professionals.