A "SAFE HANDS" HAND WASH PROGRAM
FOR RETAIL FOOD OPERATIONS:  A TECHNICAL REVIEW
 
O. Peter Snyder, Jr., Ph.D.
Hospitality Institute of Technology and Management
For: Florida Environmental Health Association, Inc., May 27, 1999
 

Introduction
The following comments relate to the overheads used for a presentation at the 51st Annual Education Conference of the Florida Environmental Health Association, Inc., May 27, 1999, in Orlando, Florida. In this presentation, I have summarized our current knowledge of the critical control points in hand washing and have recommended solutions to the problem. I have also presented information on our "Safe Hands" program, which a number of large companies are using in the United States. Other companies have been using our nail brush and hand wash method for over fifteen years. These companies have experienced virtually zero foodborne illnesses due to fecal pathogens on fingertips.


1.  Fecal pathogens on fingertips - a major cause of foodborne illness

Fingertip washing is the only control with a zero defect potential
1. "When you are sick stay home" is an ineffective government control. People are not doctors who can diagnose their illness. There are other causes for feelings of sickness and diarrhea other than Salmonella typhi, E. coli O157:H7, Shigella spp., Hepatitis A, etc.
2. Pathogens are often shed before there are illness symptoms.

Viral Hepatitis Campylobacter jejuni Listeria monocytogenes
Salmonella typhi Escherichia coli Shigella spp.
Salmonella typhimurium  
and other serotypes
Cryptosporidium spp. Giardia lamblia
3. Pathogens are also shed after people feel well. People can be carriers.
Salmonella typhi Escherichia coli Listeria monocytogenes
Shigella spp. Vibrio cholera Salmonella typhimurium  
and other serotypes
Giardia lamblia  
4. When an employee is ill, the supervisor will be aware of it. It is the supervisor's responsibility to send the employee home.
Conclusion: "When you are sick, stay home" has a high probability of failure for preventing fecal pathogens getting into food and should not be used as a hazard control method.

******
Explanation:  This overhead points out that the government control stating that when an employee is sick, he or she should stay home, is ineffective and should not be in any food regulation as a control method. Fingertip washing provides for zero defects, as will be pointed out. The principle problem is that before people have any symptoms and know that they are ill with a pathogen, they are shedding pathogens in their fecal material. It is true that when they have vomiting and diarrhea, they shed higher levels. However, we have no idea how much leaks through toilet paper and gets onto fingertips, thus creating a hazard. In addition, after people feel well, they can, and do, become carriers of these pathogens. Again, they will have no symptoms, but if they do not wash their fingertips, they will cause illness. Finally, it has been my experience in talking to supervisors that when a person is ill, those supervisors are well aware of the situation. Therefore, the best strategy is simply to leave the problem to the restaurant owner to solve. People who have taken food safety classes know very well that a major cause of foodborne illness is fecal pathogens on the fingertips. It is up to them to choose the level of risk to which they will expose their customers.


2.  Defenses of skin*
Site
Defenses
Function
Skin Dryness and acidic conditions (pH 5) 

Sloughing cells 

Resident bacteria

Limit bacterial growth 
 

Remove bacteria 

Compete for nutrients and colonization / attachment sites

Hair follicles, sweat glands Lysozyme, toxic lipids Kill bacteria
Sebum from sebaceous glands Protective film on surface of skin Prevents excessive dryness of skin
Beneath skin surface Skin associated lymphoid tissue (SALT) Kill bacteria; sample antigens on skin surface.
*References:
  • Salyers, A.A., and Whitt, D.D. 1994. Chapter 1. Host defenses against bacterial pathogens: Defenses of body surfaces. In Bacterial Pathogenesis. American Society of Microbiology Press. Washington, D. C.
  • Prescott, L. M., Harley, J. P., and Klein, D. A. 1996. Microbiology. 3rd edition. Wm. C. Brown. Dubuque, IA.
  • ******
    Explanation:  Today, many companies sell antibacterial solutions and chemicals for the purpose of making hands safe. In fact, this actually leads to damage of the skin, which then leads to less hand washing. This overhead points out the defenses of the skin and their function. It identifies the hair follicles, sweat glands, and other skin defense mechanisms. One must not interfere with these defenses; otherwise, we will have diseases of the skin and less hand washing.


    3.  Species isolated from hands of 22 health care personnel*
    Category and Species
     No. of Isolates
     Percent of Category
    Gram-positive cocci 
    Staphylococcus epidermidis 
    Staphylococcus saprophyticus 
    Staphylococcus capitus 
    Streptococcus haemolyticus 
    Alpha streptococci 
    Staphylococcus aureus 
    Staphylococcus simulans
    70
    35
    21
    16
    11
    10
    4
    39.3
    19.7
    11.8
    9.0
    6.2
    5.6
    2.2
    Gram-negative bacilli 
    Klebsiella-Enterobacter sp. 
    Acinetobacter sp. 
    Pseudomonas sp. 
    Proteus-providencia sp.
    15
    5
    4
    3
    55.6
    18.5
    14.8
    11.1
    Yeast 
    Candida parasilosis 
    Rhodotorula rubra 
    Candida albicans 
    Candida guilliermondii 
    Candida glabrata
    10
    6
    4
    4
    2
    38.5
    3.1
    15.4
    15.4
    7.7
    Total
    231
     
    *Reference:
     Adapted from Larson, E., K. J. McGinley, G. L. Grove, J. J. Leyden, and G. H. Talbot. 1986. Physiologic, microbiologic, and seasonal effects of Hand Washing on the skin of health care personnel. Am. J. Infect. Control. 14(2):51-59.

    ******
    Explanation:  Our studies at HITM have shown that when individuals rinse their hands, 1,000 to 100,000 skin microorganisms are released. This overhead lists some of these organisms and specifically identifies that the only food pathogenic organism on the skin is Staphylococcus aureus. Staphylococcus aureus, one of the resident bacteria on the hands, is normally not at a high level and poses no threat until food is abused. In this case, 10 organisms from the skin would have to multiply to 1,000,000--almost 17 multiplications--before this is a problem. Unlike hospital health care workers, there is no need to inactivate the resident S. aureus in the hands of foodservice workers, since time and temperature to prevent spoilage will control the hazard.


    4.  Types of hand care*
    Type
    Purpose
    Method
    Hand wash Remove soil and transient microorganisms Soap or detergent and friction for at least 10-15 seconds
    Hand antisepsis Remove and/or destroy transient and resident microorganisms to control infection transfer from hands Antimicrobial soap or detergent or alcohol-based hand-rub and friction for at least 10-15 seconds
    Surgical hand scrub Remove or destroy transient and resident microorganisms to control / prevent infection in patients undergoing operations Antimicrobial soap or detergent preparation with brush to achieve friction for at least 120 seconds, or alcohol-based preparation for at least 20 seconds
    *Reference:
    Adapted from: Larson, E.  1995. APIC Guidelines for Infection Control Practice. - APIC guideline for hand washing and hand antisepsis in health care settings. APIC (Association for Professionals in Infection Control and Epidemiology, Inc.).  Washington, D. C.,

    ******
    Explanation:  There are three basic types of hand care.
    1. Hand washing. Removes the soil and transient microorganisms. It can be accomplished in 10 to 15 seconds.
    2. Hand antisepsis. Involves some antimicrobial agent. There is a minimum contact time, at least 10 to 15 seconds. Each antimicrobial agent has its own characteristic. Alcohol works quickly, but other agents might take a minute. This means that people who use antimicrobial agents must make sure that they follow the minimal antimicrobial agent contact time. This is unlikely in foodservice without extreme training and enforcement.
    3. Surgical hand scrub. Destroys transient and resident microorganisms. This is used to prevent the resident bacteria of the skin getting into the patient's body during surgery or invasive care. In foodservice, the microorganisms that cause illness are typical transient bacteria from fecal material and have no relationship to the organisms of concern in medical environments.


    5.  USDA classification of hand soaps and sanitizers for use in meat processing plants

    E1 Compounds:  Hand washing compounds for use in all departments
    The compounds must be dispensed from adequate dispensers located a sufficient distance from processing lines to prevent accidental product contamination.
    -  After the use of the compounds, the hands must be thoroughly rinsed with potable water.
    -  Under conditions of use, there can be no odor or fragrance left on the hands.

    E2 Compounds:  Hand washing and sanitizing compounds
    -  The compounds must be dispensed from adequate dispensers located a sufficient distance from processing lines to prevent accidental product contamination.
    -  The hands need not be washed prior to the use of the compounds.
    -  The compounds must always be used at dilutions and according to applicable directions provided on the label.
    -  The compounds have been accepted on the basis of their equivalency to 50 parts per million chlorine.

    E3 Compounds:  Hand sanitizing compounds (hand dips)
    -  The compounds must be dispensed from adequate dispensers located a sufficient distance from processing lines to prevent accidental product contamination.
    -  The hands must be washed and thoroughly rinsed prior to the use of the compounds.
    -  The compounds may be injected directly into the wash and rinse water.
    -  The hands need not be rinsed after the use of the compound.
    -  The compounds have been accepted on the basis of their equivalency to 50 parts per million chlorine.
    * Gel-based hand sanitizers are limited to use by employees leaving the plant, unless they meet specific guidelines ensuring that residues remaining on the hands will not be inappropriate for food handling.  Only if such guidelines are met can these hand sanitizers be classified as E3.

    E4 Compounds:  Hand creams, lotions, and cleaners (including gel-based hand sanitizers not meeting E3 requirements).
    -  The use of such compounds is limited to toilets and dressing rooms.  Employees who handle edible products may use the compounds only when leaving the plant.

    *  E classifications of hand soaps and sanitizing compounds apply only to USDA-approved processing plants.  Currently, there is no classification system for hand washing products relating to foodservice establishments.

    Reference:
    Adapted from:  Miller, M. L., James-Davis, L.A. and Milanesi, L.E.  1994.  A field study evaluating the effectiveness of different hand soaps and sanitizers.  Dairy Food Envir. Sanit..  14(3): 155-160.

    ******
    Explanation:  The FDA should limit our hand washing compounds to E1 compounds. If we are going to have these ratings, the government must be responsible for establishing the measurement process. E2 and E3 compounds are a problem in the processing industry, because many employees develop reactions to these compounds. They dry the skin and cause skin problems such as dermatitis, especially during the winter. If hands are clean, transient microorganisms are gone, and E2 and E3 compounds serve no purpose. Finally, the E4 compounds (hand creams, lotions) can grow microorganisms if they do not contain antimicrobial agents in them. This can lead to skin reactions. They must be used with care.


    6.  Characteristics of selected antiseptic ingredients*
    Antiseptic Ingredient
    Action
    Negative Effect
    Alcohols 
    ethyl (ethanol), n-propyl, and isopropyl
    - Antimicrobial (denature proteins) 
    - Destroy vegetative bacteria, fungi, and viruses 
    - Emollients, if added, decrease skin drying effect
    - Have no effect on spores 
    - Alcohol pads are less effective than liquid soaps with antiseptic ingredients when used as a brief skin wipe 
    - Are not good cleaning agents 
    - Have no persistent effect 
    - Have drying effect on skin (no more than 70% alcohol / water) 
    - Are volatile and flammable and must be stored carefully
    Chlorhexidine gluconate (CHG) 
    (cationic bisbiquanide)
    - Antimicrobial (disrupts cell membranes and precipitates cell contents) 
    - Active against bacteria, some viruses (HIV, herpes, flu) 
    - Good residual effect (up to 6 hr.) 
    - Not significantly affected by organic  
    matter 
    - Available in 2 to 4% concentrations 
    - May be combined with alcohol
    - Activity is pH dependent (5.5 to 7.0) 
    - Can cause damage if instilled in ears or eyes 
    - Reports of contact dermatitis, other allergic manifestations, and anaphylaxis in sensitive individuals
     Hexachlorophene 
    (Chloronated bisphenol)
    - Disrupts microbial cell walls, precipitates cell proteins, inactivates cell enzymes 
    - Effective against gram-positive bacteria 
    - It is persistent
    - Not effective against gram-negative bacteria, tubercle bacillus, fungi, or viruses 
    - Is not fast acting 
    - Has been shown to produce neurotoxic effects 
    - General use, banned by FDA. Available by prescription only (3% concentration) 
    - Should not be used on broken skin or for bathing
    Iodine and Iodophores (complex of iodine with polyvinyl-pyrrolidone (povidone) - Antimicrobial (cell wall penetration, oxidation, and substitution of microbial content with free iodine) 
    - Active against bacteria, viruses, and fungi 
    - Some activity against bacterial spores
    - Neutralized by organic matter 
    - May cause skin irritation and damage 
    - Allergic and toxic effects in sensitive persons
    Para-chloro-meta-xylenol 
    (PCMX or chloroxylenol)
    - Antimicrobial (cell wall disruption and enzyme inactivation) 
    - Active against gram positive bacteria, some viruses, and fungi 
    - Effectiveness increased with the addition of EDTA 
    - Low incidence of skin sensitivity 
    - Persistent effect over a few hours 
    - Minimally affected by organic matter 
    - Used in a number of hand washing products (0.5 to 3.75% concentration)
    - May be less effective than CHG 
    - Rapidity of activity is intermediate
    Triclosan 
    5-chloro-2-(2,4-dichlorophenoxyl) phenol
    - Antimicrobial (cell wall disruption) 
    - Active against broad spectrum of bacteria 
    - Appears to be non-allergenic and non-mutagenic (short term), even though it can be absorbed through intact skin 
    - Has excellent persistent activity 
    - Activity is minimally affected by organic matter 
    - Has been tested in concentrations from 0.3% to 4% 
    - Is commonly used in commercial soaps (1% concentration) to reduce body odor by inhibiting the growth of skin bacteria over time 
    - Little information about effect on viruses 
    - Poor fungicide 
    - Use of this compound in soaps, mouthwashes, toothpastes, fabrics, and plastics may lead to drug resistant bacteria**
    References:
    * Larson, E. 1995. APIC Guidelines for Infection Control Practice. - APIC guideline for hand washing and hand antisepsis in health care settings. APIC (Association for Professionals in Infection Control and Epidemiology, Inc.) Washington, D. C.
    **Heath, R.J., Rubin, J.R., Holland, D.R., Zhang, E., Snow, M.E., and Rock, C.O. 1999. Mechanism of triclosan inhibition of bacterial fatty acid synthesis. J. Biol. Chem. 274 (16): 11110-11114.
     
    ******
    Explanation:  These three overheads list the major antiseptic ingredients used in antimicrobial hand soaps. Their negative effects and limited effectiveness against spores and viruses are identified. These ingredients, in some cases, are easily neutralized and will effect the skin. The only universal method that removes the appropriate microorganisms is plain hand washing.

    7.  Official test* for hand sanitizers to meet the E2 USDA criterion

    Procedure:
    1. Grow microbiological cultures to high concentrations (e.g., 108/ml).
    2. Make appropriate chemical sanitizer use solutions (e.g., standards for chlorine
    are 200, 100, and 50 ppm). The unknown test germicide would be prepared at concentrations expected to be as effective as chlorine.
    3. Add 10 mil of 200, 100, and 50 ppm chlorine to 25 x 150 mm medication tubes
    and put in a 25° C water bath. Bring to temperature.
    4. Starting with the 200 ppm tube, add 0.05 mil of test culture. Shake and return to
    the bath. After 1 minute, make a transfer to an appropriate subculture media using
    a 4 -mm flamed loop. (The subculture media tube will be used to check for viability.)
    5. At 1.5 minutes, add another 0.05 ml of the culture to the 200-ppm solution. Shake
    and return to the bath. After an additional 1 minute (2.5 minutes into the test), make
    a second subculture. In 30 seconds (3 minutes into the test), add another 0.05 ml. Shake and return to the bath. After 1 minute (4 minutes into the test), make another subculture. Repeat to give 10 total increments. (This requires a total time of 14.5 minutes and 0.5 ml of culture.)
    6. Do the same 10-tube test culture destruction test with the test disinfecting solution.
    To be considered equivalent in disinfecting activity, the unknown germicide must show the absence of growth in as many consecutive subculture tubes as the chlorine standard.

    *AOAC method 955.16 (Aoac, Official Methods of Analysis, 1995.
    The test organisms are Salmonella typhi ATCC 6539 and Staphylococcus aureus ATCC 6538.

    ******
    Explanation:  This overhead points out the method used to verify that a sanitizer meets E2 USDA criteria. It is important to point out that none of the hand sanitizers are required to be tested and validated on hands. This is a laboratory test and has no relationship to in-use effectiveness.


    8.  ASTM "glove juice" test method for evaluation of health care personnel handwash formulation

    1. Test organism = Serratia marcescens ATCC No. 14756
    2. Subjects (12) who have not used topical antimicrobials for at least 1 week; no clinical evidence of dermotosis or other skin disorders.
    3. Procedure:

    4. Enumeration of Bacteria in Sampling Solution is performed using standard microbiological techniques.
    5. Determination of Reduction. At each sampling interval, changes from baseline counts obtained with test material are determined.
    6. Comparison of Test material with a Control Material. If the test material is compared to a control material, an equivalent number of subjects should be assigned to the control product on a random basis. All test parameters will be equivalent for products.
    At each sampling interval, changes from baseline counts obtained with test material are compared to changes obtained with control material.

    **0.4 g KH2PO4 and 10.1 g Na2hPO4 and 1.0 g isoactylphenooxypolyethoxyethanol in 1 liter of water. Adjust pH to 7.8 with 0.1N HCL or 0.1 N NaOH. Dispense in 75-ml volumes and sterilize for 20 minutes at 121° C

    Reference:
    Adapted from: ASTM. 1987. Standard test method for evaluation of heath care personnel hand wash formulation. Designation E 1174 - 87. Annual Book of ASTM Standards. 11.04:779-781.

    ******
    Explanation:  When in-use effectiveness is measured the glove juice test, as described in this overhead, is used. This is a complex test using a mildly pathogenic organism, Serratia marcescens, and is not applicable to testing the removal of fecal pathogens from fingertips.


    9.  HITM procedure for measuring hand sanitation

    The feces of healthy people contains 107 to 109 E. coli / g*. E. coli is uncommon in food.

    TEST
    Use E. coli as an indicator of inadequate hand washing after using the toilet.
    Utilize Coliform / E. Coli Petrifilmä .

    1. Go into the food production facility / kitchen. Pick the 5 employees with the longest, dirtiest fingernails.
    2. Take a small separate Ziplock bag for each employee. Add 10 ml of letheen broth to each bag and have each employee rinse their work hand fingertips in the broth in their designated bag. These employees should also use a small toothpick to scrape under their fingernails. This scrapping should also be added to the letheen broth in the Ziplock bag.
    3. Plate 1 ml. of the fingertip / letheen broth culture onto Coliform / E. Coli Petrifilmä . Incubate Petrifilmä for 24 hours at 35° C.
    4. Significance of results:
       - If < 20 CFU / ml, there is no problem. (Hands have been washed adequately.)
       - If > 20 CFU / ml, there is inadequate fingertip washing.

    deWit and Rombouts* found:
       - Before stool samples 4% of kitchen employees, had >20 CFU E. coli / ml on their hands
       - After defecating 25% of the employees had >20 CFU E. coli / ml on their hands.
    The average was about 200 CFU E. coli after defecation.

    Reference:
    *de Wit, J.C., and Rombouts, F. M. 1992. Faecal bacteria on the hands of carriers: Escherichia coli as model for Salmonella. Zentralbl Hyg. Umweltmed 193(3):230-6.

    ******
    Explanation:   I have provided a method that we have used in retail food operations to measure the effectiveness of the operation's hand washing program. The test organism is E. coli, which is already naturally present in the employees' fecal material. If the employees are properly washing their hands, one would find, perhaps, a low level (<20) E. coli on a few of their hands, as the study revealed. On the other hand, if >20 E. coli were recoverable from fingertips, it was found that the employees were not washing their hands properly after defecating. In the HITM method, we used the Petrifilm&trade; Coliform / E. coli test plate. We put 10 ml letheen broth in a small, plastic, zipper bag in which the employees rinsed the thumb and first and second fingertips. Each employee then used a toothpick to clean the dirt from underneath the fingernails. In addition to being a highly effective measurement process, this is a highly effective way to warn employees that we know how to look for poor or lack of hand washing.


    10.  Control of foodborne illness pathogens:  HITM hand washing study

    1. 0.1 ml of Serratia marcescens was placed on the thumb and first and second fingers of subjects and allowed to air dry. This was a total of 20,000,000 to 100,000,000 bacteria. To test the number of S. marcescens remaining of the fingertips, the thumb, first and second finger were rubbed together in 10 ml. of letheen broth.
    2. Single wash (about 13 seconds): Liquid Ivory hand detergent was put on the hands and fingertips which were washed for 13 seconds under flowing water at 2 gallons per minute. There was a 99.7% reduction.
    3. Double wash with fingernail brush (about 20 seconds): A nail brush with about 5 ml. liquid Ivory hand detergent was used on the first wash. Then, the hands were washed again with 5 ml. more of Ivory detergent, without the nailbrush. A total of 99.999% reduction was obtained.
    4. The nailbrush was rinsed in 10 ml of phosphate buffer. Compared to the original starting bacterial counts, there was a 99.9998% reduction on the brush.
    5. The normal skin bacteria that come off in a wash are about 1,000 to 100,000 per ml of rinse water. It is critical to use a marker organism to show reduction because there is little reduction of skin resident bacteria. The brush becomes contaminated with them.

    ******
    Explanation:  This overhead summarizes the lab study we did to measure the effectiveness of the nail brush.  We put between 20,000,000 and 100,000,000 Serratia marcescens on fingertips. Using the single wash with Ivory soap, we obtained a 99.7% reduction, which is typical for hand washing. Using the double wash with the nailbrush on the first wash and friction on the second wash, we got a reduction of 99.999%. When we checked the nail brush in 10 ml phosphate buffer, we found that, based on the original starting counts, there were a few S. marcescens remaining, but there was a reduction of 99.9998% on the brush. The samples contained a lot of skin bacteria, which points out that one must use a marker organism to separate out the effectiveness of the hand washing. Relating this to the USDA concept of establishing performance standards, the FDA should set performance standards for hand washing that say that a transient marker organism (e.g., non-pathogenic E. coli) will be reduced by a minimum of 100,000 to 1 in any hand washing process that is to be approved.


    11.  When to use double and single fingertip washing

    Policy:
    All employees who prepare food in the kitchen or production area and who serve food are responsible for keeping pathogens on fingertips and hands at a safe level of <10 highly infective pathogens.

    When entering the kitchen, the double wash procedure, at the feces wash off sink, will be used to reduce high levels of pathogens (106) to a safe level:
    Upon beginning a work shift.
    After using the toilet and reentering the kitchen or production area.
    After cleaning up vomitus or any fecal material.
    After touching open sores.

    When working in the kitchen, the single wash procedure will be used to remove low levels of pathogens (103):
    Between handling raw poultry and ready-to-eat foods.

    Hand washing is not critical because it is not probable that there are >10 highly infective pathogens:
    After touching raw meat, egg shells, dirty plates, mouth, or garbage bags; blowing nose; touching skin, hair, or beard.

    ******
    Explanation:  We have always stated that there is a critical difference between the use of the nail brush and plain hand washing. When the toilet paper slips and, since fecal material can contain up to 109 pathogens per gram, there is the potential for high levels of pathogens on the fingertips. Hence, there is only one time that people need to use the nail brush--when entering the kitchen from an outside location, assumed to be the toilet. There should only be one hand wash sink designated as the feces wash-off sink in the kitchen, so that everyone understands the importance of fecal pathogens from fingertips.
    Once employees are in the kitchen, their hands become a food contact surface (e.g., cutting board, knife, food utensils) and are cleaned in a similar manner. The maximum level of pathogens that one could pick up in the kitchen on fingertips is probably 103 Campylobacter jejuni on poultry products. Scientifically speaking, raw poultry is the only food in the kitchen that requires hand washing after handling it and before touching ready-to-eat food.
    The last statement on this overhead relates to the old-fashioned idea that touching raw meat, egg shells, dirty plates, mouth, garbage bags, blowing the nose, or touching skin, hair, or beard are hazardous practices. A hamburger might contain 100 E. coli O157:H7 in a 100-gram hamburger. That is 1 per gram of hamburger. Touching the hamburger would result in picking up only a couple of E. coli--not an effective dose. Eggshells have less of a problem, because they are thoroughly washed and sanitized; there might be 1 Salmonella transferred. Dirty plates have never been shown to be a problem; the food was "clean" when it went to the customer. Through the research done on the common communion cup, it is apparent that mouth bacteria are not a food safety issue. Eating someone else's saliva does not represent a real hazard. It happens with the common cup in churches every Sunday. This means that the dish washing area is not a food safety concern. Garbage bags are full of spoilage microorganisms, but not hazards. Blowing the nose relates to S. aureus, which must multiply to a very high level and is not a hazard as it comes out of the nose. The same is true with touching hair, picking a pimple, etc. The organism must be given a chance to grow, which will not happen with the time and temperature controls that exist in the kitchen. In fact, the only critical food, again, is raw poultry in terms of cross-contamination.


    12.  Feces wash-off sink
     
  •   Stainless steel sink, 18" x 12" x 12" deep for washing up to elbows. Light: 100-foot-candles; light turns on with water flow.
  • Water flows at 2 gallons per minute, non-splash, 95-110F.
  • Automated knee switch for water.
  • Water temperature and water flow adjust valves.
  • A soft, not dense nailbrush (e.g., Anchor Surgeons Scrub 2000) for each food preparation employee. Air-dry between uses.
  • 3 to 5 ml of plain unscented liquid hand soap. Single use soap container. Employees can have their own hand soap. Visual supply. Automated push button delivery to the faucet outlet and the brush.
  • Visual towel dispenser, no lever.
  • Nose tissue.
  • Waste disposal.
  • ******
    Explanation:  This figure shows a well-designed feces wash-off sink for the kitchen. The sink is stainless steel. When the water turns on, a light of 100 foot-candles turns on over the sink, so that it is obvious that the sink is being used. Water flow is a minimum of 2 gallons per minute, because it is the water that washes the fecal pathogens off of the fingertips. The water is from 95 to 110ºF, but there is no scientific evidence to show that water temperature is critical. While faucet handles have not been shown to be a critical issue, a knee switch and soap switch will make the process go faster. Valves for water temperature and water flow are included so that the sink has adjustments to it. The nail brush is a soft-bristled brush (Anchor Surgeons Scrub 2000)--not dense--so that there is no abrasion of the skin on fingertips, and there is no collection of bacteria in the bristles. An unpublished work by Paulsen for Meritech, whereby Meritech is trying to put a brush in its automated hand washing system, shows that there is no pick-up of microorganisms on brushes. The see-through towel dispenser allows people to see how many towels are left. Nose tissues are available for people to blow their noses. Each employee has his or her own nail brush, which hangs up on a nail brush rack to dry.
    For the double wash, the employee comes up to the sink; holds the nail brush under the outlet for the soap dispenser, which is immediately by the spout; pushes the soap switch, which gives 5 ml soap onto the brush; hits the knee switch to turn on the water; the water gently flows over the fingertips while the employee brushes over the fingertips. Then, the brush is placed back on the rack. Soap is placed on the hands, and the hands are washed once more.
    The infrared units do not seem to be fast enough, so, I have chosen a simple, industrial knee switch, as is used frequently in processing plants and works quite well.


    13.  Safe hand washing
    ******
    Explanation:  This overhead depicts our colored, laminated hand wash poster, which is displayed over thousands of sinks in the U.S. today. In facilities where this poster is displayed and where they use the double wash, there is not a fecal pathogen problem. Note that the friction and volume of water are the critical variables in hand washing.

    14.  Double hand washing with a fingernail brush
     
    HAZARD CONTROL POLICIES, PROCEDURES, AND STANDARDS

    Dept.: ______________________ Person responsible: ___________________ Effective date: ____________

    Process and Output Specifications: To wash fingertips and hands to reduce by 10-5 pathogens from feces and vomit on fingertips and underneath fingernails and reduce 10-2 pathogens from food when preparing food in the kitchen.
    The Hazard: When an employee arrives from home, or after using the toilet, the employee must be assumed to have <106 pathogens on his or her fingertips and underneath fingernails. This concentration must be reduced to £10 to assure that the transfer of pathogens to the food that the employee handles is at a safe level. When working in the kitchen, an employee might touch contaminated food such as raw poultry and then, must reduce pathogens by 10-2 to reduce the pathogens to a safe level.
     

      STANDARDS AND OPERATING PROCEDURE
    Get ready. Check to see that there is an adequate supply of unscented, non-antibacterial hand detergent, an Anchor Surgeon's Scrub nail brush, and disposable paper towels at the hand sink. 
    Wet hands. Turn on the water. Let it flow rapidly at 2 gallons per minute until warm (110 to 120ºF). It is the water that removes the pathogens.  

    Apply detergent to the fingernail brush. Place enough detergent (1/2 teaspoon or 3 to 5 ml) to build a good lather on the fingers. 

    Brush and lather, particularly fingertips and fingernails. Hold the brush with the bristles up, and touch the tips of the fingers of the hand that held the toilet paper to the tips of the bristles. Gently brush the tips of the fingers, without bending the bristles, while water runs over the fingers and washes the pathogens down the drain. Continue until the brush and the fingers have no lather (about 12 to 15 seconds). If this is the first fingertip wash when coming from home, put more detergent on the nail brush and brush the fingertips on the other hand, because all fingertips could be contaminated (for example, cleaning up after animals at home). Lay the nail brush down with bristles up. This allows the water to run off so that the brush dries, and bacteria cannot multiply. 
    Second wash for additional toilet/food pathogen reduction or first wash for reduction of food pathogens to a safe level. Add 1/2 teaspoon or 3 to 5 ml of hand detergent to the palm of one hand. This wash without the nail brush reduces pathogens another 100 to 1. If it follows use of the nail brush, it gives a total of >100,000-to-1 reduction of pathogens on fingertips. When working with food, there are only moderately low levels of pathogens on fingertips, and this 100-to-1 reduction is sufficient to make the fingers safe from food pathogens. 
    Lather and wash hands (and arms if you will be mixing salad or dough). Massage the hands together and between the fingers. Wash the arms up to the tips of the shirt sleeves, if appropriate. Thoroughly rinse all of the lather from the fingertips, hands, and arms in flowing warm water. When the detergent and lather are gone from the skin, the pathogens are reduced to a safe level. 
    Dry hands using paper towel(s). Use clean, disposable paper towel(s) to thoroughly dry hands and arms. This reduces the microorganisms an estimated, additional 100 to 1. 
     
     
     

    Copyright 1997 by Hospitality Institute of Technology, 670 Transfer Road, Suite 21A, St. Paul, MN  55114   USA 

     
    ******
    Explanation:  This figure is a HACCP-style diagram of the hand wash process and should be in the FDA code in terms of teaching the principles of effective removal of fecal pathogens from fingertips. In teaching this method of hand washing, I find it effective to use Glo-Germ in the hand washing demonstration. As a modification, I have mixed brown fingerpaint with the Glo-Germ powder, rather than use the Glo-Germ oil, as my simulated fecal material. I have no trouble teaching employees the importance of fingertip washing, once they see the brown mixture on the fingertips of the demonstration volunteers.

    15.  Importance of drying hands after hand washing
     
    These simple experiments demonstrate that careful hand drying is a critical factor in determining the level of touch-contact-associated bacterial transfer after hand washing.

    The authors* designed an experiment to determine the drying efficiency of cloth towels and "air towels" (blow dryers).
    Result:  After 10 seconds of drying, single-service cloth towels removed 96% of the water from a subject's hands, whereas when hands and fingertips were dried with a blow dryer, 45 seconds drying time was needed to achieve the same endpoint.

    Another experiment showed that when materials representing skin, food, and utilities were touched with wet hands, high numbers of microorganisms were transferred from the subjects' fingers to the test material.  Microbial numbers on the order of 68,000, 31,000, and 1,900 were found on samples of skin, food, and utilities, respectively, after touch contact.
    A reduction in bacterial transfer was achieved using a simple, 10-second cloth towel or 20-second blow dryer post-wash hand drying procedure.  This 10- or 20-second drying procedure after hand washing reduced the transfer of numbers of microorganisms to skin, food, and utilities to 140, 655, and 30 respectively and achieved 99.8, 94, and 99% reductions in bacterial transfer figures associated with wet hands.

    Note:  Air dryers are known to accumulate fecal pathogens from the air in the toilet, and HITM does not recommend them for hand drying.

    Reference:
    *  Patrick, D.R., Findon, G., and Miller, T.E.  1997.  Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing.  Epidemiol. Infect.  119:319-325.

    ******
    Explanation: This overhead, then, points out the research that drying hands is a critical variable. While I have not included it in my hand washing effectiveness analysis, hand drying would increase the standard of effectiveness by a factor of 10 to 100 using relatively coarse paper towels. Barry Michaels (Georgia Pacific) has documented the effectiveness of the paper towel vs. the air dryer for the removal of pathogens.


    16.  Keeping hands clean while working in the kitchen
    Food Contact Surface Cleaning Sinks 
    Hands are a food contact surface.  
    Clean in plain single compartment sinks  
    (14" x 12" x 12") in the kitchen where other utensils are cleaned.  Only one hand sink is need for the feces wash-off sink at the entrance to the kitchen.  The equipment sink should have a high-volume water flow, some soap, and paper towels.  
     

    Bucket Hand Cleaning 
    When there is no sink (as on the food preparation line), use a 1-gallon (4-L) bucket to disinfect fingers after touching raw chicken and to keep the counter rinsed. 

  • 4 liters (4,000 ml) provides a safe dilution.  [1,000 Campylobacter jejuni is 1 bacteria / 4 ml].

  •  0.5% distilled vinegar water [400 ml of 5% vinegar in 3,600 ml of water or about 2 cups vinegar in gallon of water].
     
    ******
    Explanation: In the kitchen, the serious error has been made in terms of putting hand wash sinks throughout the kitchen. In fact, there is a lack of sinks for keeping the food contact surfaces clean--to include the hands. Actually, it would be most appropriate to remove current hand wash sinks and install simple, stainless steel sinks for the purpose of washing hands and food contact surfaces. This is not a food preparation sink, but can be used as described, or to wash out towels, etc.
    The diagram of the food contact surface wash sink shows a bat-handled faucet, an outlet with a water flow of at least 2 gallons per minutes or, perhaps, 4 gallons per minute, so that rags and towels can be rinsed effectively. There is a scrub brush at the sink for cleaning cutting boards, a soap dispenser, a sanitizer bottle, and paper towels. This way, one can squirt sanitizer on a surface and wipe with a paper towel, if appropriate, in order to reduce pathogens on the surface to a safe level. The picture also shows a two-compartment bucket with soap solution on one side and rinse water on the other side.
    In the kitchen where there is no sink close at hand, which is typical of the cook's work station, the cook would have a 1-gallon (4-liter) bucket for rinsing fingers after touching raw poultry. If one put 1,000 C. jejuni into 4 liters of water, that equates to 1 bacteria per 4 ml, which is below an infective level.
    We are now doing a study of the effectiveness of vinegar as a disinfectant in this rinse water. I believe that 0.5% vinegar solution should reduce the bacteria at least 1,000 to 1 in approximately 15 or 20 seconds. The typical quats and chlorines are actually rendered ineffective by organic and soap materials very rapidly.

    17. ABC cycle example for failure to correctly wash hands
    Antecedent
    Behavior
    Consequence
    Consequence
       
    Individual
    System
    Inconvenient location of sink 

    Lack of, or incorrect supplies 

    Employee under time pressure 

    Lack of adequate training 

    Procedure not yet habitual with employee 

    Lack of enforcement by owner/manager  

    Weak government enforcement

      

      

      

    FAILURE TO WASH HANDS CORRECTLY
    Ability to get task done more quickly/produce more items than if having to stop to wash hands, and feeling good about the progress 

    Ability to serve customer more quickly and feeling good about it 

    Possible praise from owner/manager for serving customers in a timely manner 

    Possible negative, non-instructive feedback from owner/manager

    More products being produced, and thus sold 

    Customers served in a timely manner; more customers served within a given period of time 

    Customers pleased with company's speedy service 

    No zero-defect performance in terms of correct hand washing 

    Possible customer dissatisfaction if customer sees employee not washing hands 

    Possible customer illness resulting in loss of business, liability suit, or bankruptcy

    ******
    Explanation: Management is probably the "root cause" of the hand washing problem today, because the attitude is that there is no time to train employees. The correct approach to evaluating a hand washing system is to use the ABC (antecedent-behavior-consequence) diagram. This overhead illustrates the ABC cycle when the behavior is failure to wash hands correctly.

    18.  ABC cycle example for correct hand and fingertip washing in a behavior-controlled TQM system
    Antecedent
    Behavior
    Consequence
    Consequence
       
    Individual
    System
    Automated top-quality, well-lit hand and fingertip washing station at the employee entrance to the kitchen 

    Adequate supplies present; back-up readily available 

    Employee under time pressure, but time to wash hands and fingertips is insisted upon by management 

    Customers are aware of management's attention to food safety 

    Adequate training in correct hand and fingertip washing procedure 

    Procedure is habitual with employee 

    Immediate, certain enforcement of behavior by owner/manager is expected; employee is fired upon failure to wash hands and fingertips

     
     
     
    CORRECT HAND AND FINGERTIP WASHING 
    100 PERCENT OF THE TIME 
    Ability to get task done and to serve customer, and feeling good about knowing that the customer will be served safe food as a result of hand and fingertip washing 

    Positive feedback from owner/manager for following this critical safety procedure 

    Job is retained

    Appropriate number of products being produced, and thus sold 

    Customers served in a timely manner 

    Customers pleased with attention paid to food safety 

    Zero-defect performance in terms of liability costs 

    Possible customer dissatisfaction if customer is in a hurry and needs immediate service, but easy to assuage by employee saying, "I did not want to take the chance of making you ill."

    ******
    Explanation: This cycle shows the antecedents and consequences for correct hand and fingertip washing. Note that it is very important that the consequences be positive and rewarding in order to instill in employees the desire to wash fingertips correctly when they enter the kitchen.

     19.  Industry checklist of an effective government program
     
    1. The head of state food safety program writes a semi-annual fact sheet on safe hand washing.
    2. The state has an up-to-date file of the latest research reports on safe hand washing.
    3. All food safety inspectors can validate safe hand washing with the E. coli test.
    4. All food safety inspectors can demonstrate safe hand washing (the official state method).
    5. All food safety inspectors can verify a unit's safe hands program.
    6. Inspectors give all employees a 10-minute written knowledge test during an inspection.
    7. There is an annual industry / government meeting to improve the state safe hands program. Ten (10) government and ten (10) industry people are randomly selected each year and are required to meet and review the program.
    8. The state keeps statistics, which are updated monthly, on percent of food employees checked that month that could correctly demonstrate safe hand washing.
    9. The government must have epidemiological proof of cause of illness for every requirement they have in the state code, to include hand washing.

    ******
    Explanation: A major problem nationwide is that there is no initiative to lead a hand washing program in the states. The sanitarians have different ideas for what they want, and there is no knowledge. Hence, the first step in an effective national program is to tell the industry that the state has the responsibility for correct knowledge. The nine factors shown in the overhead are critical elements that I teach the foodservice industry to require of the state food safety leaders so that the state is held accountable for providing correct knowledge.


    20.  Government risk assessmentof the probability of safe fingertip washing in a retail food operation

    1. The manager has an up-to-date file of semi-annual fact sheets from the state on hand washing. The manager can demonstrate the correct procedure for fingertip washing.
    2. The manager has a signed written test for hand wash mastery for all employees that show the employees:
        - Were trained in safe hand washing.
        - Viewed the state hand wash video.
        - Demonstrated to the manager that they could double-wash their hands.
    3. The manager has a monitoring and reward program for hand washing
    4. Five (5) employees, chosen at random, can correctly demonstrate the double-hand wash. Some are tested for E. coli under the fingernails.
    5. Employees are retrained and tested every 6 months.

    ******
    Explanation: The question is, then, how does one correctly evaluate the probability of correct hand washing in a retail food operation. The five items in this overhead explain the critical variables that should be examined during a government risk assessment of a hand washing program. It begins with a state-mandated program that managers must follow, and all employees must know. That program must have been validated as being effective in actual operation.


    21.  Unit HACCP hand wash policy
    Safe Hand Washing Policy
    Our establishment is committed to the well-being of our employees and our customers. To prevent foodborne illness, a critical part of that commitment is frequent and proper hand washing, including proper use of the fingernail brush. 

    All employees will be trained and certified in safe hand washing before being allowed to work with food. Employees will be constantly positively reinforced for following correct procedures.  
    An employee who has difficulty remembering will be retrained.  
    An employee who does not wish to practice safe hand washing will not be employed. 

    We will expect nothing less than total compliance with this policy, since our jobs depend on it. We have the tools to prevent 

    ________________                                              __________________________ 
                Date

    ******
    Explanation: A part of the evaluation of the unit program is management commitment. This overhead shows a simple commitment statement that should be posted by the cash register at the front of the restaurant. It states management's commitment to employees and customers alike in terms of serving safe food.

    22.  Safe hand washing checklist

    Planning and Pre-control
    ____Owner sets the example.
    ____Owner checks on and reinforces performance.
    ____Employees participate in control.
    ____Hand sink is maintained and stocked.
    ____Fingernail brush is replaced when worn.
    ____There are written hand washing procedures that are kept current and used for training.
    ____No one is allowed to handle food until trained and certified in safe hand washing.
    ____There is an effective punishment for not washing hands when returning from the toilet.
    ____The hand sink produces water at 110 to 120°F in 5 seconds. The water flows at
    2 gallons / 8 liters per minute.
    ____The soap lathers well, and effectively and speedily removes filth from the hands and fingertips.
    ____There are nose tissues by the sink. Handkerchiefs are banned. If a person must sneeze or cough, he or she does so away from the food, into a shoulder, but never into hands.
    ____There are good-quality, non-latex gloves available if an employee needs them.

    Organization and Training
    ____Responsibility for training and employee safe hand washing certification is clearly defined.
    ____Every employee has seen the safe hand washing video tape and has been performance certified using Glo-Germ.
    ____Every six months, employees receive hand washing refresher training.

    Operation and Control
    ____The sink is always restocked before any supply is less than 1/4. There are back-up supplies near the sink, and employees can restock the sink supplies if necessary.
    ____Employees check each other and provide team reinforcement in correct fingertip and hand washing.
    ____All employees can properly demonstrate safe hand washing.
    ____There is control of cuts on hands.
    ____Employees wearing gloves wash or change the gloves frequently.
    ____Fingernails are kept very short.

    Measuring and Feedback
    ____Supplies never run out.
    ____Employees participate in improving the system.
    ____Safe hand washing is continuously positively reinforced by management.

    ******
    Explanation:  This overhead shows a list that I have developed and use to evaluate the effectiveness of a hand wash program in a retail food operation. It is quite thorough, and if a facility follows even a part of what is listed, there will be no food safety issue in terms of hand washing.


    23.  Summary
     
    1. How to achieve safe hands is no mystery. It is being done most of the time.
    2. The state must have one basic procedure, on videotape, for removal of fecal pathogens on fingertips, and everyone in retail food operations must do the procedure. There must be verifiable research data that proves the procedure does reduce pathogens on hands and fingertips to a safe level. It must be shown that this is the minimum effective procedure.
    3. In the kitchen, the raw food and ready-to-eat food must be separated and employees must clean-as-they-go. They must clean hands between handling raw chicken and ready-to-eat food.
    4. The percent of correct performance by employees must be measured and recorded by the manager and at the state level.
    5. Good performance behavior must be rewarding, not punishing.
    6. The government must inform the consumer what actions do not warrant immediate hand washing. These are:
        - putting fingers to mouth
        - tying shoes
        - blowing nose
        - bussing dishes
        - touching dirty rags, etc.

    It is the industry's responsibility to provide quality and customer satisfaction.

    ******
    Explanation: This presentation points out that there is no mystery to achieving safe hands. A number of my clients who have used nail brushes for 20 years do not have foodborne illness incidents caused by inadequate hand washing. They represent about 5,000 food establishments of various types. The process begins with correct knowledge, which, today, should be provided by the state. Everyone in the state should use the same method. The state is responsible for validating in a kitchen that the process achieves a 100,000-to-1 reduction of pathogens on fingertips. Both the state and management, then, measure correct performance by testing employees periodically to find out how they are doing. their performance must be rewarded by the state. It is up to the government to tell consumers that putting fingers in the mouth, tying shoes, blowing the nose, bussing dishes, and touching dirty rags are not a food safety issue, that fecal pathogens on fingertips are the critical problem, and the hand washing procedure takes of it.


    24.  HITM's national "Safe Hands" program components

    Starter kit.
    1. Manager's Information on Safe Hand Washing
    2. Employee Safe Hand Washing Policies, Procedures, and Standards
    3. Video tape: Safe Hand Washing (English or English / Spanish)
    4. Safe Hand Washing Policy
    5. Employee Safe Hand Washing Test and Record
    6. Safe Hand Washing Checklist
    7. Safe hand washing poster for above the hand sink
    8. Anchor surgeon's brush: Super Scrub #2000B
    9. Glo-Germ kit: orange fluorescent powder in mineral oil for hand washing training; white tracking powder to show what people touch and how they transfer germs; fluorescent light to cause the powder to "glow" in a darkened room
    10. "Safe Hands" Certification Sheet
    11. "Safe Hands" Recertification Sheet
    12. "Safe Hands" Employee Certification Pin (10 pins for initial training)

    Upon completing your initial "Safe Hands" training, contact HITM to receive the following.
    1. "Safe Hands" Customer Brochure (packet of 25 for customer distribution and original for photocopying)
    2. "Safe Hands" Dated Wall Certificate

    For each retraining, contact HITM to receive recertification materials.
    1. Personalized "Safe Hands" Wallet-size Employee Recertification Certificate (for each recertified employee)
    2. "Safe Hands" Dated Wall Certificate (for recertification, showing ongoing commitment to "Safe Hands")
    3. "Safe Hands" Customer Brochure (packet of 25 for customer distribution)

    ******
    Explanation: This overhead is a table of contents for our national "Safe Hands" program, which we have provided for approximately three years. We can provide it to anyone--including the FDA.


     25.  Hand washing on the HITM website

    A "Safe Hands" hand wash program for retail food operations.
    (http://www.hi-tm.com/Documents/Safehands.html):
    If hand and fingertip washing is to be enforced, there must be agreement on the actual method and then, retail foodservice training and enforcement. This document sets forth a national initiative for safe hands in the USA and the world.

    Double hand washing with a fingernail brush.
    (http://www.hi-tm.com/Documents/Handflow.html):
    Illustrated with step-by-step photographs, this 1-page document shows the standards and operating procedure for safe hand washing using the double hand washing procedure with a fingernail brush. The hazard and process and output specifications are described.

    Hand washing.
    (http://www.hi-tm.com/Documents/handwash.html):
    This is a listing of abstracts from over 130 articles dealing with the problem of washing hands.

    ******
    Explanation: This overhead lists three major resources on our website, which anyone can download and use. 


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