oversight

School Meal Program: Few Instances of Foodborne Outbreaks Reported, but Opportunities Exist to Enhance Outbreak Data and Food Safety Practices

Published by the Government Accountability Office on 2003-05-09.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to Congressional Requesters




May 2003
             SCHOOL MEAL
             PROGRAMS
             Few Instances of
             Foodborne Outbreaks
             Reported, but
             Opportunities Exist to
             Enhance Outbreak
             Data and Food Safety
             Practices




GAO-03-530
                                               May 2003


                                               SCHOOL MEAL PROGRAMS

                                               Few Instances of Foodborne Outbreaks
Highlights of GAO-03-530, a report to
Congressional Requesters                       Reported, but Opportunities Exist to
                                               Enhance Outbreak Data and Food Safety
                                               Practices

More than 28 million children                  GAO found that 195, or about 3 percent, of the total of 7,390 foodborne
receive meals daily through the                outbreaks that were reported nationwide, between 1990 and 1999, occurred
federal school meal programs.                  in schools. Specific national data on whether these outbreaks were related
Providing meals that are safe is               to the federal school meal programs do not exist; however, GAO’s survey of
especially important because                   state health officials provided information on 40 large outbreaks involving
young children have a higher risk
of complications from some
                                               these programs. Nearly half of these large outbreaks resulted from improper
foodborne illnesses. GAO                       food preparation and handling practices in school kitchens. Most commonly,
examined (1) the frequency and                 foods involved in the outbreaks were contaminated with Norwalk-like
causes of reported foodborne                   viruses, which cause a mild gastrointestinal illness. However, data
illness outbreaks associated with              limitations make comprehensive assessment of the safety of school meal
the federal school meal programs               programs difficult. In particular, the reporting mechanism that states use to
and (2) the practices that federal,            voluntarily report outbreaks to the Centers for Disease Control and
state, and local governments as                Prevention (CDC) does not distinguish between outbreaks in schools
well as other food providers find              involving the school meal programs and those involving food from other
useful for safeguarding meals.                 sources, such as brought from students’ homes.

                                               Federal, state, and local governments, as well as other food providers use a
GAO recommends that the                        variety of practices to safeguard meals. Some of them may have national
Secretary of Health and Human                  applicability to the federal school meal programs. For example, having key
Services direct the Director of CDC            food service personnel trained and certified in food safety would address the
to modify the Centers’ foodborne               improper food preparation and handling practices that caused most of the
outbreak reporting mechanism to                outbreaks reported in GAO’s survey. Purchasing precooked or irradiated
add federal school meals as an                 meat and poultry products could reduce the risk of foodborne illness in
outbreak category.                             schools. Furthermore, the U.S. Department of Agriculture requires that some
                                               of the commodities it donates to schools be purchased under more stringent
GAO also recommends that the
Secretary of Agriculture direct                safety standards than the agency’s regulatory requirements for meat and
(1) the Administrator of the                   poultry processors. Currently, these more stringent procurement
Agricultural Marketing Service                 requirements are not readily accessible for school districts’ use. While the
(AMS) to highlight its more                    practicality of applying these food preparation/handling and purchasing
stringent school-related                       practices to the nation’s schools has not been assessed, several food safety
procurement specifications on the              experts believe that applying these practices in all schools would enhance
agency’s Web page and                          the safety of federal school meals. Some of these practices would likely lead
(2) the Administrators of AMS and              to increased food costs for schools.
the Food and Nutrition Service to
further promote training and
certification of key food service
personnel and study the advantages
and disadvantages of donating
precooked or irradiated foods.

USDA and HHS agreed with this
report’s recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-03-530.

To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Lawrence J.
Dyckman at (202) 512-3841 or
dyckmanl@gao.gov.
Contents


Letter                                                                                  1
               Results in Brief                                                         3
               Background                                                               5
               School Meals Caused the Majority of Foodborne Outbreaks in Our
                 Survey of School Foodborne Outbreaks                                   7
               Selected Government and Private Practices Could Enhance Overall
                 Food Safety in Schools                                               14
               Conclusions                                                            25
               Recommendations for Executive Action                                   26
               Agency Comments and Our Evaluation                                     26

Appendix I     Scope and Methodology                                                  29



Appendix II    State Health Departments’ Survey Results                               33



Appendix III   GAO’s Analysis of CDC Data                                             39



Appendix IV    Food Safety and Security Practices for School Meal
               Programs Used or Suggested by Government or
               Private Sector                                                         52



Appendix V     Comments from the Department of Health and
               Human Services                                                         61



Appendix VI    GAO Contacts and Staff Acknowledgments                                 63
               GAO Contacts                                                           63
               Acknowledgments                                                        63


Tables
               Table 1: Number of Reported Foodborne Outbreaks and Related
                        Illnesses, Hospitalizations, and Deaths, 1973-1999            41


               Page i                                      GAO-03-530 School Meals Safety
          Table 2: Number of Reported Foodborne Outbreaks Resulting from
                   Foods Prepared in Restaurants, Private Homes, Schools,
                   and in Other Locations, 1973-1999                               42
          Table 3: Number of Illnesses Associated with Reported Foodborne
                   Outbreaks Resulting from Foods Prepared in Restaurants,
                   Private Homes, Schools, and in Other Locations, 1973-1999       42
          Table 4: Number of Illnesses Associated with Reported Foodborne
                   Outbreaks Resulting from Foods Prepared in Restaurants,
                   Private Homes, Schools, and in Other Locations, by State,
                   1973-1999                                                       43
          Table 5: Reported Foodborne Outbreaks Per 100,000 Population,
                   by State, 1973-1999                                             45
          Table 6: Number of Reported Foodborne Outbreaks in Five States
                   Reporting the Largest Numbers, 1973-1999                        47
          Table 7: Food Safety and Security Practices for School Meal
                   Programs Used or Suggested by Government or Private
                   Sector                                                          53


Figures
          Figure 1: GAO Analysis of CDC Outbreak Data and GAO Survey
                   Responses on Large School Outbreaks Associated with
                   the Federal School Meal Programs, 1990-1999                      9
          Figure 2: Total Number of Reported Outbreaks, 1973-1999                  48
          Figure 3: Total Number of Illness Associated with Reported
                   Outbreaks, 1973-1999                                            49
          Figure 4: Number of Reported Outbreaks, by Where Food Was
                   Prepared, 1973-1999                                             50
          Figure 5: Number of Outbreaks in States Reporting the Largest
                   Number of Outbreaks, 1973-1999                                  51




          Page ii                                       GAO-03-530 School Meals Safety
Abbreviations

AMS               Agricultural Marketing Service
ASFSA             American School Food Service Association
CDC               Centers for Disease Control and Prevention
FDA               Food and Drug Administration
FNS               Food and Nutrition Service
FSIS              Food Safety and Inspection Service
HACCP             Hazard Analysis and Critical Control Point
HHS               Department of Health and Human Services
USDA              United States Department of Agriculture




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Page iii                                                 GAO-03-530 School Meals Safety
United States General Accounting Office
Washington, DC 20548




                                   May 9, 2003

                                   The Honorable Tom Harkin
                                   Ranking Minority Member
                                   Committee on Agriculture, Nutrition, and Forestry

                                   The Honorable Richard G. Lugar
                                   United States Senate

                                   More than 28 million children receive meals daily in almost all of the
                                   nation’s public schools, and in many private schools, through the federally
                                   funded National School Lunch Program and School Breakfast Program.
                                   The principal goals of these programs—which cost the federal government
                                   an estimated $8 billion in fiscal year 2002—are to provide low cost or free
                                   meals to children and to help support the agricultural economy. These
                                   meals are generally safe, but our analysis of data from the Centers for
                                   Disease Control and Prevention (CDC) shows that 195 outbreaks of
                                   foodborne illness were reported in schools between 1990 and 1999. These
                                   outbreaks involved about 12,000 individuals.1 Food safety in schools is
                                   especially important because children have a higher risk of complications
                                   from some foodborne illnesses. For example, children are particularly
                                   susceptible to Escherichia coli (E. coli) O157:H7, a dangerous bacterium
                                   that has been found in undercooked meat and other foods and which can
                                   lead to kidney failure and death.2 According to CDC, children between the
                                   ages of 1 and 9 have the highest infection rate for E. coli of all age groups.
                                   School food safety is also important because outbreaks involving school
                                   children have a greater number of illnesses on average. According to our
                                   analysis of CDC data, while school foodborne outbreaks from all schools
                                   constituted less than 4 percent of total U.S. foodborne outbreaks reported
                                   to CDC from 1973 through 1999, they were responsible for about



                                   1
                                    Our analysis of CDC’s school outbreak data includes outbreaks associated with public and
                                   private elementary and high schools. CDC school outbreak data also includes outbreaks
                                   associated with colleges and universities. We excluded these outbreaks in order to have
                                   outbreak data more relevant to our review.
                                   2
                                    E. coli O157:H7 produces a potent toxin that damages the lining of the intestines. Severe
                                   abdominal cramping and bloody diarrhea characterize the resulting illness. About 2 to
                                   7 percent of infections result in hemolytic uremic syndrome, which destroys red blood cells
                                   and causes kidney failure. Hemolytic uremic syndrome affects children more often than
                                   adults.



                                   Page 1                                                   GAO-03-530 School Meals Safety
10 percent of all outbreak-related illnesses during this period. In fact, a
single outbreak can involve many children. For example, in 1998,
1,700 individuals were sickened by burritos served by school cafeterias in
several states.

The U.S. Department of Agriculture’s (USDA) Food and Nutrition Service
(FNS) administers the school meal programs at the federal level. At the
state level, state education agencies typically administer and monitor the
programs through agreements with local school districts’ food authorities.
FNS provides about 17 percent of the dollar value of food served at
schools by donating commodities such as meats, poultry, dairy products,
fruits, and vegetables. A key aspect of the programs is the removal of
surplus commodities from the marketplace. Local school food authorities
commercially purchase about 83 percent of the food served in the lunch
and breakfast programs using federal per-meal cash reimbursements and,
to a lesser extent, their own funds.

To prepare for the reauthorization of the Richard B. Russell National
School Lunch Act and to improve the safety of school meals, you asked us
to (1) determine the frequency and causes of reported foodborne illness
outbreaks associated with the federal school meal programs and
(2) identify practices that federal, state, and local governments as well as
other food providers find useful for safeguarding meals from unintentional
and deliberate contamination.3

To respond to your first concern, we analyzed CDC’s foodborne outbreak
database. CDC asks states to voluntarily report outbreaks of foodborne
illness, but they are not asked to provide information on the frequency and
causes of foodborne outbreaks specifically associated with the federal
school meal programs. As a result, the database does not distinguish
between illnesses caused by meals provided through the federal school
meal programs and other sources, such as food brought from home.
Consequently, we conducted a Web-based survey of state health officials
that reported school outbreaks involving 50 or more individuals between
1990 and 1999 to determine which of these outbreaks involved federal




3
 GAO prepared an additional report describing nutrition in school meals to support the
reauthorization of the Richard B. Russell National School Lunch Act. See U.S. General
Accounting Office, School Lunch Program: Efforts Needed to Improve Nutrition and
Encourage Healthy Eating, GAO-03-506 (Washington, D.C.: May 9, 2003).




Page 2                                                   GAO-03-530 School Meals Safety
                   school meals.4 We also asked these survey respondents and other state
                   health officials not included in our survey their opinions on how to
                   enhance CDC’s outbreak reporting mechanism. To respond to your second
                   concern, we contacted food safety experts, including FNS federal school
                   meals officials and officials from the American School Food Service
                   Association (ASFSA)—the national school food service worker
                   professional association, to identify school districts that are known to
                   have useful food safety practices or are facing food safety challenges. In
                   addition, we discussed useful food safety practices with state and local
                   education and health officials. We also contacted private sector and other
                   food providers regarding their useful food safety practices. Further details
                   on our scope and methodology are discussed in appendix I.


                   Our analysis of CDC data shows that 195 foodborne outbreaks in U.S.
Results in Brief   schools were reported from 1990 through 1999—representing about
                   3 percent of the 7,390 reported outbreaks during that period. Information
                   provided to us by state health officials on 59 large outbreaks (involving
                   50 or more people) at schools shows that 40 were associated with meals
                   served through the federal school meal programs. These outbreaks
                   affected about 5,500 individuals. The remaining 19 outbreaks were caused
                   by foods from other sources, such as students’ homes. Nineteen of the
                   40 outbreaks related to the school meal programs resulted from improper
                   food preparation and handling practices within the schools, while
                   8 outbreaks were due to foods contaminated before delivery to the
                   schools, or to a combination of poor school preparation/handling practices
                   and before-school contamination. It is not known where the food involved
                   in the remaining 13 outbreaks was contaminated. In terms of the agents
                   that caused the foodborne disease involved in these 40 outbreaks, we
                   found that Norwalk-like viruses, which cause a mild gastrointestinal
                   illness, were the most frequently reported agent. It is important to note
                   that several data limitations make routine, accurate, and comprehensive
                   assessments of federal school meal safety very difficult. As CDC points
                   out, all foodborne illnesses, including those associated with federal school
                   meals, are underreported. Moreover, the reporting mechanism that states
                   use to voluntarily report outbreak data to CDC does not ask states to
                   distinguish between outbreaks that are caused by foods provided through
                   school meal programs and those involving foods from other sources. Food



                   4
                    Because the outbreaks included in our survey are not a representative sample, the survey
                   results cannot be generalized.




                   Page 3                                                   GAO-03-530 School Meals Safety
safety experts told us that one possible way of improving CDC’s data
would be to revise the reporting mechanism by adding a specific category
for federal school meals. This could yield somewhat better data on the
frequency and causes of reported foodborne illness associated with the
federal school meal programs and help both FNS and state and local
officials determine if additional actions are needed to reduce foodborne
illness in schools. Forty-six health department officials we contacted in
the 50 states and the District of Columbia concurred and said they could
provide this additional information with minimal difficulty if asked to do
so. Five health officials said that they could not provide this information.

Federal, state, and local governments, as well as other food providers, use
a variety of practices that they consider useful to safeguard meals. These
providers as well as other food safety experts told us that four of these
practices have the potential to enhance the safety of the federal school
meal programs. These practices offer the added benefit of helping to
safeguard school meals from deliberate contamination. The four practices
are (1) employing key food service personnel who are trained and certified
in food safety practices, (2) implementing a risk-based approach for safely
preparing, storing, and serving foods (such a system should identify
potential hazards and establish controls to mitigate or reduce their
occurrence), (3) purchasing precooked or irradiated meat and poultry
products, and (4) applying the more stringent purchasing specifications
that USDA uses when purchasing some of the food commodities it donates
to schools. Specifically, USDA’s procurement specifications require that
these commodities be processed under safety conditions that exceed
federal regulatory requirements for processing of meat, poultry, and other
food products. Currently, these specifications are not easily found because
USDA lists them in procurement documents undifferentiated from
standard federal food safety requirements. The practicality of applying
one, or some combination, of these four practices to the nation’s schools
has not been assessed. While experts believe that requiring these practices
would enhance safety, mandating that school districts require training, a
risk-based safety approach, and stringent procurement requirements
would likely necessitate legislative changes at the federal level and lead to
increased food costs for schools. Similarly, if USDA donated only
precooked or irradiated products, food costs would likely increase.

To improve data on outbreaks that are directly associated with federal
school meals, we recommend that CDC modify the reporting mechanism
that states use to voluntarily report foodborne outbreaks. In addition, to
enhance the safety of school meals, we recommend that USDA make its
stringent purchasing specifications more readily accessible. We also


Page 4                                          GAO-03-530 School Meals Safety
             recommend that USDA further promote the training and certification of
             key school food service personnel in food safety practices. Finally, we
             recommend that USDA study the advantages and disadvantages of
             donating only precooked or irradiated meat and poultry. Since, as we
             recently reported, school meal programs’ revenues in selected states have
             not kept pace with expenses, we stress that such a study should take
             added costs into consideration.

             We provided HHS and USDA with a draft of this report for their review
             and comment. We received written comments from HHS and oral
             comments from USDA on the report’s contents and recommendations.
             Both agencies agreed with the report’s recommendations and provided
             technical comments, which we have incorporated as appropriate.


             USDA’s Agricultural Marketing Service (AMS) and Farm Service Agency
Background   are responsible for procuring USDA-donated foods used to prepare meals
             for the National School Lunch Program and the School Breakfast
             Program.5 AMS purchases meat, egg products, poultry, fish, nuts, and fruits
             and vegetables for donation; Farm Service purchases grains, oils, peanut
             products, dairy products, and other foods. USDA contracts for the
             purchase of these products with manufacturers that it selects through a
             competitive bidding process. FNS, through its Food Distribution Division,
             administers the program and donates foods to state agencies for
             distribution to schools to meet a portion of schools’ needs. Schools then
             purchase the remainder of food for school meals using their own
             procurement procedures, either purchasing foods directly from
             manufacturers or distributors or contracting with food service
             management companies that procure the foods for them.

             USDA and the Food and Drug Administration (FDA) have ongoing
             responsibility for ensuring the safety of the nation’s food supply. USDA
             regulates meat, poultry, and egg products, while FDA regulates all other
             foods. Within USDA, FNS provides food safety guidance to schools and
             state agencies that emphasizes proper food handling and personal hygiene.
             For example, FNS provides schools manuals that address appropriate
             temperatures for reheating ready-to-eat foods and for maintaining foods at
             appropriate temperatures to avoid hazardous contamination. Similarly,



             5
              The School Breakfast Program is authorized by the Child Nutrition Act of 1966, as
             amended.




             Page 5                                                   GAO-03-530 School Meals Safety
    FNS provides information on employee personal hygiene and how it
    relates to cross-contamination of foods. FNS also provides schools posters
    and other food safety-related materials.

    As we have reported, CDC monitors foodborne diseases through a variety
    of systems. The one most relevant to this review is the Foodborne Disease
    Outbreak Surveillance System, created in 1973 to collect data about cases
    of foodborne disease contracted by two or more individuals as a result of
    ingesting a common food.6 The system covers all 50 states, the District of
    Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands and all types of
    pathogens, including bacteria, chemicals, parasites, and viruses. In the
    event of a foodborne outbreak, state and local public health department
    officials can voluntarily provide data to the system about the pathogen
    that caused the outbreak, if known; the contaminated food that was
    involved; and factors that contributed to the outbreak. These officials
    submit this information to CDC using a paper form or its electronic
    counterpart. Analysis of the data shows whether outbreaks occur
    seasonally and whether certain foods are more likely than others to
    contain pathogens. The data help focus public health actions intended to
    reduce illnesses and deaths caused by foodborne disease outbreaks. The
    data also helps public health officials identify critical control points in the
    path from farm to table that can be monitored to reduce food
    contamination. However, the data from this system do not always identify
    the pathogen responsible for a given outbreak; such identification may be
    hampered by delayed or incomplete laboratory investigation, inadequate
    laboratory capacity, or inability to recognize a particular pathogen as a
    cause of foodborne disease. In addition, according to CDC officials, the
    outbreak surveillance system does not distinguish whether the source of a
    school foodborne outbreak was from the federal school meal programs or
    other sources such as food brought from home.

    Foodborne outbreaks that have recently occurred in schools include the
    following:

•   From October 1997 through October 1998, 16 outbreaks of foodborne
    illness associated with eating burritos occurred in 7 states. All but one of
    these outbreaks occurred in schools, and most of the approximately
    1,700 victims were children. Children involved in this outbreak became ill


    6
     See U.S. General Accounting Office, Food Safety: CDC Is Working to Address Limitations
    in Several of Its Foodborne Disease Surveillance Systems, GAO-01-973 (Washington, D.C.:
    Sept. 7, 2001).




    Page 6                                                GAO-03-530 School Meals Safety
                      shortly after consuming the burritos. The cause of the outbreak was never
                      determined.

                  •   In March 1997, an outbreak of hepatitis A caused by contaminated
                      strawberries donated by USDA sickened more than 200 teachers and
                      students in Michigan and about 50 people in other states.7 Thousands of
                      other students in the affected states received gamma globulin injections as
                      a preventive measure after being exposed to the contaminated
                      strawberries.

                  •   In October 1998, 11 children were infected by E. coli O157:H7 in school
                      lunch taco meat in Finley, Washington. Three of these children developed
                      hemolytic uremic syndrome, a potentially fatal disease that can result in
                      anemia and kidney failure. A jury found that the school district was at fault
                      and awarded $4.75 million to the affected children, including at least
                      $3.8 million for one child who is expected to need multiple kidney
                      transplants in her lifetime. This award is currently being appealed.


                      Nationwide data on the frequency and causes of foodborne outbreaks
School Meals Caused   associated with the federal school meal programs do not exist. But,
the Majority of       according to our survey of state health officials, about two-thirds of the
                      foodborne outbreaks involving 50 or more individuals that occurred in
Foodborne Outbreaks   schools from 1990 through 1999 were caused by meals served through the
in Our Survey of      federal school meal programs. In addition, our survey shows that nearly
                      half of those outbreaks resulted from improper food preparation and
School Foodborne      handling practices within schools, such as improper food storage and poor
Outbreaks             food service worker hygiene. Recent studies conducted by CDC and FDA
                      are generally consistent with our findings. However, the CDC study and
                      our analysis point out that significant data limitations make it difficult to
                      assess the overall safety of school meals nationwide. In particular, CDC’s
                      national database on foodborne outbreaks does not currently contain
                      sufficiently detailed information on federal school meal-related outbreaks.




                      7
                      Fatigue, poor appetite, fever, vomiting, and jaundice characterize hepatitis A infections.




                      Page 7                                                    GAO-03-530 School Meals Safety
Our Survey of State Health   Our analysis of CDC data shows that 195 foodborne outbreaks were
Officials Shows That about   reported in schools from 1990 through 1999. To obtain more information
Two-Thirds of the            on federal school meal-related outbreaks than is currently available from
                             CDC’s database, we obtained data from health officials regarding 59 large
Outbreaks We Examined        school outbreaks that occurred in 25 states. Large outbreaks are those that
Involved Foods Served        involve 50 or more individuals. State health departments are typically
through the School Meal      involved in the initial investigation and subsequent reporting to CDC of
Programs                     foodborne outbreaks and are, therefore, able to provide more detailed
                             information. Specifically, we asked state health officials whether foods
                             served through the federal school meal programs, as opposed to foods
                             brought into schools from home or other sources, were the cause of
                             59 large outbreaks that occurred in school buildings between 1990 and
                             1999.8 The state health officials reported that, according to their outbreak
                             investigations, the federal school meals caused two-thirds of the outbreaks
                             (40 of the 59). Other foods eaten at schools, such as foods brought from
                             home or foods served at special events (i.e., fundraisers) caused the other
                             19 outbreaks. Figure 1 shows the number of outbreaks that occurred in
                             schools and the number of individuals who became ill after consuming
                             breakfast and/or lunch provided through the federal school meal
                             programs. Although our results cannot be generalized beyond the 59 large
                             outbreaks included in our survey, they provide an indication of the
                             frequency and causes of foodborne illness associated with the federal
                             school meal programs.




                             8
                              Outbreaks included in the survey are not a representative sample, and results from the
                             survey are not projectable. Our survey did not include outbreaks that involved less than
                             50 individuals. Furthermore, many outbreaks that occur in schools are not reported, or the
                             information provided to public health authorities is incomplete.




                             Page 8                                                   GAO-03-530 School Meals Safety
Figure 1: GAO Analysis of CDC Outbreak Data and GAO Survey Responses on
Large School Outbreaks Associated with the Federal School Meal Programs,
1990-1999



                                   CDC data
                       195 foodborne outbreaks in schools
                             12,733 related illnesses



                                 GAO survey
                                59 foodborne
                         outbreaks in schools involving
                            50 or more individuals
                            7,501 related illnesses



              School meals                      Non-school meals
         40 foodborne outbreaks               19 foodborne outbreaks
          5,530 related illnesses              1,971 related illnesses


Source: GAO and CDC.

Note: These data represent updated information provided by CDC since our report: U.S. General
Accounting Office, Food Safety: Continued Vigilance Needed to Ensure Safety of School Meals,
GAO-02-669T (Washington, D.C.: Apr. 30, 2002).


In addition to asking whether the reported outbreaks involved meals
provided through the federally funded school meal programs, we asked
state health officials about factors that may have contributed to the
outbreaks. The officials reported that 19 of the 40 outbreaks associated
with school meals resulted from poor food preparation and handling
practices within school kitchens. These poor practices include inadequate
cooking, improper food storage and handling, poor food worker hygiene,
sick workers preparing food, and improper hot holding and cooling of
foods. Specifically, improper food storage and poor food service worker
hygiene were each reported in more than half of the 19 outbreaks caused
by poor food preparation and handling practices. Improper holding
temperatures for hot foods, improper food handling, and improper cooling
of foods were other frequently reported problems that contributed to the
outbreaks. Only 6 of the 40 outbreaks were caused by foods that were
contaminated before delivery to the school: for example, strawberries
contaminated with Hepatitis A and prepared burritos contaminated with a
still unidentified substance. In 2 outbreaks, state health officials told us
that food contaminated before delivery and poor food preparation
practices within the school kitchen both contributed to the outbreaks. The


Page 9                                                       GAO-03-530 School Meals Safety
                            cause of the remaining 13 outbreaks attributed to federal school meals has
                            not been determined.

                            Our survey also asked state health officials about the types of illnesses
                            associated with federal school meal outbreaks. In 8 of the 40 outbreaks
                            that the health officials attributed to the school meal programs, the agent
                            that caused foodborne illness was never identified. However, of those that
                            were identified, Norwalk-like viruses were the most frequently reported
                            cause of illness, associated with 8 of the 40 outbreaks. Norwalk-like
                            viruses cause a mild gastrointestinal illness that lasts for 24 to 60 hours
                            and that can be transmitted through food or water contaminated by
                            humans or from one infected person to another. Staphylococcus aureus,
                            the second most common cause of illness, was reported in 7 of the
                            40 outbreaks. It commonly results in diarrhea and vomiting that start
                            suddenly within 1 to 6 hours of eating a contaminated food. Patients
                            generally recover within 2 days. Salmonella and Clostridium perfringens
                            were reported in 5 and 4 of the 40 outbreaks, respectively. Salmonella
                            causes a gastrointestinal illness and can lead to other serious health
                            problems, including arthritic symptoms and blood poisoning. Clostridium
                            perfringens causes intense cramps and diarrhea. Illness is usually over
                            within 24 hours, but some symptoms may persist for 1 to 2 weeks. The
                            remaining 8 of the outbreaks involved other disease-causing agents,
                            including Shigella, hepatitis A, and Bacillus cereus.9 Appendix II provides
                            further information about our survey to state health department officials.


CDC and FDA Studies Are     CDC recently reported on outbreaks that occurred in schools between
Generally Consistent with   1973 and 1997.10 That report was not specific to federal school meal
Our Findings Regarding      outbreaks; moreover, it included colleges and universities. Although CDC’s
                            findings are generally consistent with those of our survey, CDC reported
the Causes of These         that the cause of illness in 60 percent of the outbreaks was unknown. In
Outbreaks                   addition, CDC reported that Salmonella was the most frequent cause of
                            illness (36 percent of outbreaks with a known cause of illness) while
                            Staphylococcus aureus and Clostridium perfringens were the second and



                            9
                             Bacillus cereus causes abdominal cramps and diarrhea that usually last for 24 hours.
                            Shigella causes more severe abdominal cramps and diarrhea, usually lasting 5 to 7 days.
                            Many strains of Shigella produce a potent toxin that destroys tissue.
                            10
                             Daniels, Nicholas A. et al. “Foodborne Disease Outbreaks in United States Schools.” The
                            CDC study was published in the Pediatric Infectious Disease Journal, Volume 21,
                            Number 7, July 2002.




                            Page 10                                                 GAO-03-530 School Meals Safety
third most frequently reported causes of illness.11 CDC also reported that
improper storage and holding temperatures and likely contamination by a
food handler were the most commonly reported food preparation
problems. As compared with our survey results, CDC reported that
Norwalk viruses were the cause of illness in relatively fewer outbreaks,
perhaps because tests for Norwalk-like viruses were unavailable for much
of the time period covered in the CDC report, 1973 through 1997. In fact, in
another recent CDC-sponsored study, CDC researchers suggested that
Norwalk-like viruses are the likely cause of many outbreaks reported to
CDC with unknown causes.12 Our survey also identified fewer outbreaks of
unknown cause than the CDC school foodborne illness study because our
survey focused only on large outbreaks, which are more likely to be
thoroughly investigated. Lastly, the CDC school illness study also points
out limitations in the foodborne outbreak surveillance data, including
underreporting of outbreaks.

In 2000, FDA reported on the occurrence of foodborne illness risk factors
in food service facilities, including elementary schools.13 FDA designed the
study to provide a national baseline on the prevalence of different risk
factors for foodborne illness. Specifically, investigators evaluated
compliance with the 1997 FDA Food Code to determine the presence of
risk factors.14 Risk factors investigated fell into five categories: food from
unsafe sources, inadequate cooking, improper holding temperatures,
contaminated equipment, and poor personal hygiene. This study was also
generally consistent with the results of our survey. The study found that
the food safety risk factors most frequently found in elementary schools
were improper handwashing by food service workers (47 percent of
observations were out of compliance), improper holding temperatures of
cold potentially hazardous foods (45 percent of observations were out of



11
 The differences between our results and CDC’s results may be due to the fact that our
analysis is based on a much smaller sample and a shorter time period than CDC used for its
analysis.
12
 Fankhauser, Rebecca L., et al. “Epidemiologic and Molecular Trends of ‘Norwalk-like
Viruses’ Associated with Outbreaks of Gastroenteritis in the United States.” The CDC study
was published in the Journal of Infectious Diseases, Volume 186, July 2002.
13
  Food and Drug Administration, Report of the FDA Retail Food Program Database of
Foodborne Illness Risk Factors, August 2000.
14
  The Food Code represents FDA’s guidance for a uniform system of regulation for
ensuring that the foods sold or offered for human consumption in restaurants, grocery
stores, schools, and nursing homes are safe, properly protected, and honestly presented.




Page 11                                                  GAO-03-530 School Meals Safety
                            compliance), and bare-hand contact with ready-to-eat foods (34 percent of
                            observations were out of compliance).

                            The food preparation risk factors FDA found in elementary schools are
                            very similar to the most frequent causes of outbreaks in schools that CDC
                            reported and that we found through our survey of state health officials.
                            Even though FDA’s study focused on risk factors and not on actual
                            outbreaks, all three studies found that holding temperatures and
                            contamination by food handlers are key risk factors for foodborne illness.
                            In particular, the FDA study demonstrates that food preparation
                            deficiencies are underlying risk factors in all elementary schools and are
                            not limited to elementary schools where outbreaks have occurred. All
                            three studies demonstrate the importance of food safety training for
                            school food service personnel in reducing school foodborne illness.


Available Data Limit        Several important data limitations make routine, accurate, and
Nationwide Assessment of    comprehensive assessment of food safety in the school meal programs
the Frequency and Causes    very difficult. First, as CDC acknowledges, only a small percentage of all
                            foodborne illness outbreaks are reported by state health officials. These
of Illnesses Associated     health officials voluntarily report foodborne outbreaks to CDC using a
with Federal School Meals   paper or electronic form. Data from both of these forms are combined in
                            the Foodborne Disease Outbreak Surveillance System. A key reason for
                            underreported foodborne illnesses is that few people actually seek
                            treatment. In addition, when people do seek treatment, few illnesses are
                            properly diagnosed, confirmed through laboratory analysis, and then
                            reported to the CDC surveillance system.

                            The substantial variability in reporting practices among states is a second
                            data-limitation factor. Because CDC does not have statutory authority to
                            require states to report foodborne outbreaks or any other diseases, states
                            report on a voluntary basis. CDC officials told us that some states are
                            more proactive than others in reporting foodborne outbreaks. In fact, our
                            analysis of state outbreak reporting trends shows a wide variance in
                            reporting practices across states. For example, from 1973 through 1999,
                            reported outbreaks per 100,000 people ranged from 66 in Hawaii to 1 in
                            Mississippi. Although CDC guidance defines a foodborne illness outbreak
                            as two or more cases of a similar illness resulting from the ingestion of a
                            common food, in practice, many states investigate and, hence, report only
                            larger outbreaks often because of limited resources. Appendix III provides
                            further information about CDC’s outbreak data and the variations in
                            reporting across states.



                            Page 12                                         GAO-03-530 School Meals Safety
A third data-limitation factor is that the forms states use to voluntarily
report outbreaks to CDC do not distinguish outbreaks associated with the
school meal programs from other outbreaks that occur in a school setting.
For example, a well-known 1997 outbreak caused by hepatitis
A-contaminated strawberries is identified in CDC’s database as having
occurred in a school, but could not be attributed to the federal school
meal programs. FNS and others acknowledge that the strawberries were
served through the school lunch program.

To address this third limitation, we contacted state health officials in all
50 states and the District of Columbia to assess the practicality of adding
the choice of “federal school meal” to the foodborne illness outbreak
reporting form that states use to report outbreaks. Forty-six of the
51 health officials said either that they have the information needed to
specify which outbreaks are due to the federal school meal programs or
that they could obtain this information if they knew it was needed. Five
health officials said that they could not provide this information. Finally,
several health officials we contacted told us they were uncertain about the
definition of a federal school meal. Consequently, any change to the CDC
reporting form would need to include a precise definition of “federal
school meal” for health officials to use. CDC defines any terms that might
be unclear on the instructions that accompany the form. CDC officials
have said that modifying the form has merit and would not be difficult, and
they are amenable to such a change. Furthermore, several food safety
experts we contacted said that making this change would yield somewhat
better data on foodborne illnesses associated with the federal school meal
programs. USDA’s Food Safety and Inspection Service (FSIS) officials
noted that this change might intensify investigative efforts to establish the
food vehicle, the causative agent, and the likely point of contamination so
that corrective and preventative measures can be implemented. 15




15
 FSIS is the public health regulatory unit within USDA that regulates all meat, poultry, and
egg products sold in interstate commerce.




Page 13                                                   GAO-03-530 School Meals Safety
                          Federal, state, and local governments, as well as other food providers, use
Selected Government       a variety of practices to safeguard meals. According to several food safety
and Private Practices     experts we consulted, four of these practices could be applied in all
                          participating schools to enhance the safety of the federal school meal
Could Enhance             programs. First, many of the school districts we contacted require training
Overall Food Safety in    and certifying of food service workers. Second, several school districts use
                          risk-based food safety procedures. These two practices could remedy a
Schools                   major cause of foodborne outbreaks identified in our study; namely, poor
                          food preparation and handling practices. Third, several school districts
                          purchase precooked meat and poultry products to help reduce the risk of
                          foodborne pathogens, and some food safety experts suggest irradiating
                          these products could also reduce these risks. Fourth, USDA’s stricter food
                          procurement requirements could help improve the safety of school meals.
                          Lastly, after the events of September 11, 2001, most of the schools we
                          visited had reviewed existing measures to prevent deliberate
                          contamination of school meals, but had adopted few additional safeguards
                          regarding food security. However, some food safety measures we
                          identified during our review, such as restricting access to food preparation
                          areas, could also help protect school meals against deliberate
                          contamination.


Training and Certifying   Nine of the 14 local school districts we contacted required training and/or
School Food Service       certification of school food service workers to help ensure that foods
Workers Enhance Food      served in the federal school meal programs are safe to eat. Food safety
                          certification training addresses topics such as proper procedures to safely
Safety                    receive, store, prepare, and serve food. Food safety experts we contacted
                          believe that certification provides a level of assurance that key personnel
                          are trained in proper food safety practices.

                          The practice of also requiring certification of food service managers is
                          widespread in the food service industry as well as in most of the schools
                          we visited. Specifically, food service managers were required to be
                          certified in food safety in 8 of the 14 schools districts we contacted.
                          Moreover, as of January 2003, 17 states and 70 local jurisdictions in several
                          additional states required or will require some form of training
                          certification for food service managers, according to the National
                          Restaurant Association Education Foundation.16 This means that nearly



                          16
                           Food manager certification requirements for Pennsylvania and Indiana become
                          mandatory in July 2003 and December 2004, respectively.




                          Page 14                                               GAO-03-530 School Meals Safety
60 percent of the U.S. population will soon consume food prepared by
certified food service managers.

Similarly, several private sector food service providers we contacted,
including Jack in the Box, a national restaurant chain, and Walt Disney
World, also require food safety training and certification. For instance, a
Jack in the Box representative told us that the company ensures that all its
food managers are certified through the National Restaurant Association’s
“ServSafe” food-safety training program.17 Jack in the Box also provides a
1-day modified “ServSafe” training course for key food service workers. In
addition, Jack in the Box uses only certified trainers for its own training
program and ensures that its workers are trained on critical food safety
points at each restaurant workstation. The company also communicates
the significance of food safety by showing its workers a video on food
safety responsibilities and actual cases of foodborne illnesses and their
impact on children. According to Walt Disney World representatives, the
company requires that all its food establishments comply with state food
safety certification requirements and uses both “ServSafe” and the
National Register of Food Safety Professionals to train and certify
employees. Food safety concepts introduced through training are
reinforced on a daily basis through signs and newsletters and by providing
food safety information on an intranet site.

Furthermore, the Veterans Health Administration, a division of the
Department of Veterans Affairs that serves about 100,000 meals daily,
requires 20 hours of food safety training annually for all food service
workers. The Veterans Health Administration’s health care facility
managers also select key food service workers to be “ServSafe” certified.
Lastly, food safety experts and advocacy groups we contacted, such as the
AFSFA, the Conference for Food Protection, the Center for Science in the
Public Interest, and Safe Tables Our Priority support the concept of
mandatory nationwide training and certification of key food service
workers, such as schools’ food service managers, supervisors, or head
cooks.18



17
 “ServSafe” includes training on topics such as foodborne illnesses; microbial
contaminants; safe food handling, purchasing and receiving safe food, safe food storage,
safe food preparation and service; and food safety regulation and standards.
18
  The Conference for Food Protection is a nonprofit advocacy group made up of food
industry, government, academia, and consumer organizations that addresses food safety
issues and certifies food safety training programs.




Page 15                                                  GAO-03-530 School Meals Safety
                            Certification courses for food service workers are available from several
                            sources. Certification courses include that of ASFSA, the National
                            Environmental Health Association, and others approved by the
                            Conference for Food Protection, such as courses of the National
                            Restaurant Association and the National Registry of Food Safety
                            Professionals. As of February 2003, about 27,000 persons had been
                            certified by ASFSA. Certification requirements may be fulfilled by
                            completing the “Serving It Safe” food safety course developed by FNS and
                            the National Food Service Management Institute.19 In addition, 1.5 million
                            food service workers have been certified by National Restaurant
                            Association’s “ServSafe” food safety training program.

                            While we found broad support for voluntary food safety training of food
                            service workers, some stakeholders—certain school districts, state and
                            local education and health agencies, and others—we contacted had mixed
                            opinions about the need for or practicality of mandating certification
                            requirements. Supporters believe that a federal certification requirement is
                            a practical minimum threshold to help ensure safer food service
                            operations in all school districts. Skeptics expressed concerns about the
                            benefit of mandatory federal certification because of the costs and time
                            involved in acquiring certification and monitoring and standardizing
                            training programs. These concerns may be especially applicable to rural or
                            small school districts. Officials at one school district where the health
                            department requires all food service managers to be certified told us that
                            they were barely able to pay for food service workers’ examination fees,
                            yearly certification costs, and textbook expenses, especially with the high
                            turnover of food service employees. In addition, USDA officials say that
                            such a mandate would necessitate a legislative change because USDA
                            currently lacks such authority under the Richard B. Russell National
                            School Lunch Act or the Child Nutrition Act of 1966.


Using Risk-Based Food       Some school food service operations we visited were required by state or
Safety Procedures           local health authorities to follow food safety procedures based on the
Strengthens Schools’ Food   Hazard Analysis and Critical Control Points (HACCP) system. HACCP is a
                            risk-based system that identifies where contamination is mostly likely to
Safety Efforts              occur and then establishes controls to prevent or reduce food


                            19
                              The Institute is a congressionally established FNS-funded resource center at the
                            University of Mississippi dedicated to continuous improvement of child nutrition programs.
                            Its “Serving It Safe” course includes training on topics such as food safety, preventing
                            foodborne illness, microorganisms, and sanitary food service.




                            Page 16                                                 GAO-03-530 School Meals Safety
contamination.20 The school districts we visited used some aspects of the
HACCP system for preparing, storing, and serving food. For example, they
had easy-to-use HACCP-based inspection checklists, such as those
provided by FNS or others for monitoring food service operations that
enable supervisors to assess the implementation of food safety
procedures, such as frequency of food temperature checks.

FNS supports and encourages voluntary HACCP training for school food
service personnel. For example, FNS provides to schools the National
Food Service Management Institute’s “Serving It Safe” course, which is
based on HACCP principles. The course helps food service workers
understand risk-based principles and develop and implement a HACCP
plan. Institute officials told us that, as of September 2002, over
250 individuals from 45 states had attended its Instructor Orientation to
HACCP for Child Nutrition Programs. As a direct result of this training,
these instructors provided local training to nearly 1,700 participants in
20 states. Several school districts, state and local educational and health
agencies, and food safety experts told us that key elements of HACCP-
based systems, such as monitoring food temperatures frequently, is very
important for food safety. Some also said that having easy-to-use food
inspection checklists to record HACCP-based practices should be required
elements of any school food service operation. These checklists are
available from a variety of sources, including FNS’s HACCP-based
voluntary guidance for school food safety. FNS also makes available on-
line recipes that include HACCP information.

Private sector food providers we contacted also implement risk-based
food safety approaches to food preparation and handling. For instance,
Walt Disney World told us that it uses a HACCP approach in all its food
service locations, which includes checking and recording the appropriate
temperatures for cooking, hot holding, cold holding, cooling, and reheating
of foods. The company also uses daily and weekly self-inspection
checklists to monitor items such as employee hygiene, equipment and
facility sanitation, food storage, pest control, and garbage disposal. To
prevent or reduce cross-contamination, the company requires the proper
use of gloves and differently colored cutting boards designated for


20
 HACCP is well known in the U.S. food processing industry. As part of their food safety
oversight responsibilities, USDA and FDA require meat, poultry, seafood, and fruit and
vegetable juice processors to use HACCP to limit the spread of foodborne disease-causing
pathogens. Food establishments are required to adopt monitoring procedures, corrective
actions, verification procedures, and record-keeping procedures.




Page 17                                                 GAO-03-530 School Meals Safety
different types of food. Officials from Sodexho, a national food service
management company, said it uses similar food safety practices in its
HACCP plan. The company employs an independent audit firm to verify
compliance with the plan by conducting unannounced audits of its
facilities. Finally, the Veterans Health Administration has a nationwide
food safety policy that includes a HACCP requirement in all its facilities.
Veterans Health Administration officials told us that monitoring devices
are used to continuously record temperatures of food storage areas, even
during power outages.

Some food safety experts said that mandating HACCP principles to all
participating schools would enhance the safety of federal school meals.
However, some school districts and state and local education and health
agencies expressed reservations about mandating a comprehensive
HACCP system, such as the one adopted by New York City, because of its
costs. New York City’s HACCP plan for schools, which is part of a program
mandated by the city’s Office of School Food and Nutrition Services, is
240 pages long. It contains detailed guidance, instructions, checklists, and
logs for activities such as monitoring critical control points. Some school
food service managers and others told us that small and rural school
districts would be challenged to implement such an extensive effort. In
addition, some food service managers told us that some HACCP
requirements are complicated and could present a challenge to food
service workers who may have limited educational backgrounds or who
do not speak English as their primary language—common issues among
school food service workers.21 Also, school districts that do not cook
meals from scratch but instead rely on prepackaged meals would need less
extensive risk-based plans for food service workers. As a result, HACCP
requirements would have to be modified to reflect schools’ various food
service operations. USDA officials told us that mandating HACCP in
schools would necessitate a legislative change because USDA currently
lacks such authority under the Richard B. Russell National School Lunch
Act or the Child Nutrition Act of 1966. Lastly, if HACCP-based systems
were used, several food safety experts told us that monitoring and
enforcing these systems would be essential for their full effectiveness.



21
 Some school districts prepare or use food safety training and other materials in languages
other than English. For example, officials from Montgomery County, Maryland’s Food and
Nutrition Service Division, told us that they offer food safety training in English, Spanish,
and Chinese. Also, FNS is expanding its efforts to provide school food safety-related
materials in Spanish.




Page 18                                                   GAO-03-530 School Meals Safety
Using Precooked or         According to some food safety experts, proper precooking or irradiation
Irradiated Meat and        would eliminate or reduce potential pathogens from raw meat and poultry
Poultry Products Reduces   and thus decrease the possibility of foodborne disease outbreaks in school
                           meals.22 Some school districts, including six we contacted, use precooked
Food Contamination Risks   meat or poultry products to a large extent. This practice is supported by
                           several private sector food service providers and by food safety experts.
                           Specifically, food safety experts state that purchasing meat that has been
                           precooked to proper temperatures is an effective way to minimize the risk
                           of E. coli O157:H7 and Salmonella, which are frequently found in raw
                           meat, and in the case of Salmonella, raw poultry. By eliminating the need
                           to cook raw meat items after they arrive at the school district, schools may
                           also reduce labor costs and eliminate the need for some equipment. For
                           example, in February 2001, the Minnesota Department of Children,
                           Families & Learning’s Food and Nutrition Service sent a notice to all
                           school authorities recommending that all raw meat, whether obtained
                           from USDA or purchased from commercial sources, be reprocessed into
                           fully cooked products to minimize the risks associated with E. coli
                           O157:H7 contamination. This advisory followed an E. coli O157:H7
                           outbreak in a Minnesota school.

                           USDA already purchases some precooked meat and poultry products for
                           donation to schools and other nutrition programs. According to USDA’s
                           most recent study of nationwide school food acquisitions, in terms of cost,
                           USDA provided more than half of the precooked ground beef and almost
                           half of the precooked beef patties used at schools during the 1996-97 fiscal
                           year.23 However, USDA does not have similar information on its purchases
                           of poultry products. Nevertheless, during fiscal year 2002, AMS purchased
                           16.4 million pounds of cooked diced chicken; 5.5 million pounds of cooked
                           cut-up chicken; and 5.3 million pounds of cooked chicken fajita strips,
                           patties, and nuggets for donation.

                           However, USDA officials said that precooking meat and poultry adds to
                           the cost of those foods and could reduce the overall amount of USDA-
                           donated commodities provided to local school districts. For example, raw
                           chicken costs USDA about 50 cents per pound, and precooked chicken
                           costs USDA about $1.35 per pound. Specifically, USDA officials told us
                           that requiring USDA to donate only precooked meats or poultry would


                           22
                            Irradiation involves exposing food briefly to radiant energy (such as gamma rays or high-
                           energy electrons) to reduce or eliminated microorganisms that can contaminate food.
                           23
                            USDA, School Food Purchase Study: Final Report, (Washington, D.C.: Oct. 1998).




                           Page 19                                                  GAO-03-530 School Meals Safety
decrease the amount of those commodities that USDA could donate by
shifting more funds to pay for the costs of processing rather than the costs
of acquiring raw products. It would also lessen the impact of USDA’s
efforts to remove surpluses of those commodities from the marketplace,
one of the goals of the school meal programs. According to FNS officials,
donating only precooked meats or poultry would reduce a given school
district’s ability to select the commodities based on local schools’
preferences and specifications. Although there are no available costs
estimates, some experts believe that the additional expense of precooking
certain high-risk foods may be offset by the savings in health care costs
associated with school foodborne outbreaks.

Another more controversial technique to reduce bacteria in meat and
poultry is irradiation. Proper irradiation of foods would kill 99.9 percent of
Campylobacter jejuni and Listeria monocytogenes, as well as E. coli
O157:H7 and Salmonella—foodborne pathogens that are associated with
meat and poultry.24 FDA and USDA have approved irradiation for reducing
pathogens in raw meat and poultry products,25 and some food safety
experts suggest that irradiation should be used on the meat and poultry
products that USDA donates to the federal school meal programs. In
addition, scientific organizations, including the American Dietetic
Association, the American Medical Association, CDC, and the World
Health Organization, have endorsed food irradiation. Other entities,
however, such as the Consumer Federation of America, the Center for
Science in the Public Interest, the Physicians Committee for Responsible
Medicine, and Public Citizen, oppose serving irradiated foods to children
pending more study on its long-term health effects. In 2000, we reported
that scientific evidence indicates that the benefits of food irradiation
outweighed the risks.26

USDA is taking actions concerning the possible introduction of irradiated
food into the federal school meal programs, and a decision of whether to
purchase irradiated products is pending. Currently, USDA does not donate



24
 Campylobacter jejuni is a bacterium that causes diarrhea and may cause fever,
abdominal pain, nausea, headache, and muscle pain. Infection is most common in children
under 5 and young adults.
25
  FSIS issued final regulations, effective in February 2000, that specified appropriate
irradiation dosage levels.
26
 See U.S. General Accounting Office, Food Irradiation: Available Research Indicates That
Benefits Outweigh Risks, GAO/RCED-00-217 (Washington, D.C.: Aug. 24, 2000).




Page 20                                                    GAO-03-530 School Meals Safety
any irradiated meat and poultry products to the federal school meal
programs. According to USDA officials, a provision in the Farm Security
and Rural Investment Act of 2002 directs USDA to allow any food safety
technology approved by USDA or the Department of Health and Human
Services, including irradiation, to be used for commodity purchase
programs, including the federal school meal programs. In November 2002,
USDA requested public comments on implementing this provision. USDA
plans to publish its irradiation policy for commodity donations later on in
2003. USDA officials noted that costs are associated with the irradiation
process and that irradiated products available in consumer markets cost
more than nonirradiated products. Therefore, irradiating donated meat
and poultry products could add to the cost of these foods and, without
additional program funding, could reduce the overall amount of USDA-
donated commodities provided to local school districts.

At the local level, federal regulations do not prohibit schools from serving
irradiated foods should they choose to purchase them commercially.
Although we found that irradiated meat and poultry are available in many
parts of the nation for commercial purchase at local outlets or from food
distributors, no schools are known to currently serve irradiated foods,
according to the ASFSA and FNS. Regarding irradiation, food safety
experts believe that certain issues need to be addressed, including
whether the schools would serve irradiated foods, how related
notifications to school children and their parents would be handled, and
the extent to which students would have alternatives to irradiated food
items. In this regard, FNS provided a grant to the Minnesota Department of
Children, Families & Learning for development of an educational pilot that
will include materials for school staff and parents regarding food safety
and the use of irradiated foods as one option to ensure a safe food supply.
USDA is to receive a final report on the pilot, including prototype
educational materials by September 2003. Also, FNS plans to distribute to
state agencies and school districts publications developed by FDA and
FSIS to respond to common food irradiation questions.

Although precooking and irradiation may be viewed as key approaches to
eliminating foodborne disease, food safety experts and USDA note that
neither practice provides an absolute guarantee against foodborne disease
and stress that proper preparation and handling of irradiated and
precooked meats is still needed. USDA is reviewing the comments it
received in response to a request for public input on these food safety
technologies and has not made a final decision on implementation of the
congressional mandate. Spokespersons for four entities we contacted—
the Conference for Food Protection, the National Food Service


Page 21                                        GAO-03-530 School Meals Safety
                             Management Institute, the National Restaurant Association, and Resources
                             for the Future—and others caution that irradiating and precooking foods
                             do not protect the food from recontamination through mishandling by
                             food service workers during meal preparation.


USDA Has Established         As we reported in February 2000, USDA has established policies and
Contracting Specifications   procedures to further ensure the safety of foods purchased for donation to
for Enhancing the Safety     schools.27 In particular, AMS’s procurement contracts for school-donated
                             foods include provisions that specify more stringent testing than is
of Foods It Donates to       required by USDA’s FSIS and by FDA. According to AMS officials, AMS
Schools                      developed these provisions because it believes that the nation’s school
                             children warrant food safety-related protections that are more stringent
                             than those applied to the nation’s population in general.

                             Under AMS’s more stringent procurement specifications, suppliers of food
                             products that pose microbial contamination concerns—i.e., beef, poultry,
                             and eggs—are subject to stricter pathogen testing. Specifically, contracts
                             for diced chicken specify pathogen testing for every lot because the
                             product is susceptible to contamination. Also, while FSIS’s regulations
                             require that raw ground beef destined for the general public be subject to a
                             series of random sample testing for Salmonella,28 with a standard of no
                             more than 7.5 percent of each sample being positive for Salmonella, AMS
                             contracts require that all production lots of raw ground beef destined for
                             school donation receive E. coli O157:H7 and Salmonella testing, both with
                             a zero tolerance. Finally, AMS’s procurement contracts establish specific
                             temperature requirements during transportation from processing plants to
                             the final destination. Accordingly, the trucks or railcars used to transport
                             meat or poultry products and frozen or chilled fruit and vegetable
                             products must have refrigeration units capable of maintaining the required
                             temperatures. AMS also requires satisfactory annual plant surveys for
                             suppliers of processed fruits and vegetables.

                             These procurement policies and procedures that are to safeguard foods
                             donated to schools, do not apply to foods purchased by local schools.
                             Since local schools purchase about 83 percent by value of the food served


                             27
                               See U.S. General Accounting Office, School Meal Programs: Few Outbreaks of Foodborne
                             Illness Reported, GAO/RCED-00-53 (Washington, D.C.: Feb. 22, 2000).
                             28
                              FSIS regulations require that raw ground beef be sampled on consecutive days of
                             production over a given period of time.




                             Page 22                                                GAO-03-530 School Meals Safety
through the federal school meal programs, some food safety experts, such
as representatives of the Conference for Food Protection and Resources
for the Future, believe that USDA should require school districts to
purchase foods according to AMS’s more stringent specifications.
However, mandating that schools use the stricter purchasing
specifications would necessitate a legislative change because USDA
currently lacks such authority under the Richard B. Russell National
School Lunch Act or the Child Nutrition Act of 1966. Furthermore, USDA
officials say that practical challenges exist for many schools in
implementing its more stringent specifications. Specifically, food suppliers
of small or rural school districts where there is limited competition for
school business, might not bid for food contracts because of the increased
cost associated with meeting the requirements. As a result, schools might
face significantly higher costs and have access to fewer suppliers. Also,
many districts do not purchase foods directly from processors but rather
rely on food distributors, food brokers, and/or food service management
companies to purchase the foods served in their schools. According to
AMS, these businesses may be reluctant to pay higher wholesale prices for
products meeting specific purchase requirements.

An alternative to mandatory purchasing specifications would be to make
USDA’s more stringent requirements more readily accessible to school
districts and allow them to decide whether to use the requirements.
Officials at several school districts we contacted and representatives from
the Consumer Federation of America and Resources for the Future told us
that having these food safety specifications readily available to schools for
their own commercial food purchases would be useful in promoting food
safety. Accessing such information is currently difficult because AMS lists
these specifications in its commodity procurement documents along with,
and undifferentiated from, standard federal safety requirements. For
example, the few paragraphs containing stricter purchase specifications
for microbiological testing are contained in a 28-page AMS commodity
specification for frozen cooked diced chicken. AMS officials told us that
the idea of extracting the specifications and prominently displaying them
on the AMS Web page to make them more accessible to interested school
officials has merit and would not be burdensome. AMS said that while
these specifications are developed for specific processes and products and
may be useful in helping schools develop their own food purchases
specifications, they should not be applied universally to all situations and
products.

As discussed earlier, the practicality of applying USDA’s purchasing
practices and other useful practices we identified to all the nation’s


Page 23                                         GAO-03-530 School Meals Safety
                               schools would depend on the size of the school district, the resources
                               available to it, and the way each district prepares and serves meals. In
                               addition, as we have recently reported, for school year 1996-97 through
                               2000-01 expenses associated with federally funded school meals in
                               selected states have increased faster than revenues.29 Nevertheless, some
                               food advocacy organizations, including the Center for Science in the
                               Public Interest and the Consumer Federation of America, believe that the
                               absence of minimum national safety requirements for the federal school
                               meal programs reduces the assurance that all school districts have basic
                               food safety practices in place. They believe that creating national
                               requirements for these programs would enhance the safety of school
                               meals. Furthermore, the Center for Science in the Public Interest and
                               other food safety experts believe that four food safety practices in
                               particular—training and certification of food service workers, using risk-
                               based food safety procedures, using precooked and irradiated meat and
                               poultry products, and applying AMS’s stricter purchasing specifications—
                               warrant further study of their national applicability, including the
                               advantages and disadvantages, such as increased costs. These experts
                               believe that such a study should address school districts’ resource
                               constraints, the potential impact on the school meal programs’ commodity
                               surplus removal mission, and the need to request any specific legislative
                               authorization.


Some School Districts Are      After the events of September 11, 2001, some school district officials said
Reemphasizing Food             that they had reviewed their food security procedures for preventing
Security Practices after the   deliberate contamination of school meals and while they found them to be
                               adequate, were reemphasizing them. However, beyond reemphasizing
Events of September 11,        existing procedures to prevent deliberate contamination, the school
2001                           districts we contacted had not taken many additional measures to address
                               food security. Several of the measures implemented to help ensure food
                               safety, such as tight controls over loading docks where schools receive
                               food deliveries or restrictions on access to food preparation areas, are
                               equally important to improving security. Regarding new security measures,
                               one district official had visited local food suppliers especially to review
                               their food security practices to protect products such as bread, juice, and
                               milk from deliberate contamination. Officials at other school districts that




                               29
                                See U.S. General Accounting Office, School Meals Programs: Revenue and Expense
                               Information from Selected States, GAO-03-569 (Washington, D.C.: May 9, 2003).




                               Page 24                                              GAO-03-530 School Meals Safety
              we visited told us that they routinely visit facilities of new or existing food
              suppliers to ensure the safety and security of suppliers’ operations.

              To strengthen school districts’ efforts to prevent deliberate contamination
              of school meals, FNS has drafted school-specific food security guidance,
              which includes sections on supplier selection and personnel and
              operational security. This guidance will supplement more general
              voluntary guidance on food security that USDA and FDA have developed
              for dissemination to food producers, processors, and providers.30 The
              voluntary guidance includes FSIS’s 2002 security guidelines for meat,
              poultry, and egg processors, which contain sections on security for
              storing, shipping, and receiving food products.31 As of March 2003, FNS
              had not established an issuance date for its guidance for school districts.
              We believe that this guidance is comprehensive and thorough and should
              facilitate school districts’ efforts to better protect school meals from acts
              of deliberate contamination.

              A more complete list of the useful school food safety and food security
              practices that we identified during our review is contained in appendix IV.


              School and other government officials currently lack accurate and
Conclusions   comprehensive data on the frequency and causes of foodborne illness
              outbreaks associated with the federal school meal programs. A more
              accurate picture of the magnitude and causes of foodborne illness
              outbreaks in the school meal programs is needed to determine how much
              to invest in food safety practices and where to focus resources. Such
              information is of particular importance because children have a higher
              risk of complications from some foodborne illnesses and because of the
              considerable financial investment by American taxpayers in the federal
              school meal programs. In addition to obtaining more accurate and
              comprehensive data on the frequency and causes of foodborne illness,
              options exist to help minimize the occurrence of foodborne outbreaks in
              schools at both the local and federal levels. However, the costs associated
              with implementing any additional measures should be carefully




              30
               See U.S. General Accounting Office, Food-Processing Security: Voluntary Efforts Are
              Under Way, but Federal Agencies Cannot Fully Assess Their Implementation,
              GAO-03-342 (Washington, D.C.: Feb. 14, 2003).
              31
               USDA, FSIS Security Guidelines for Food Processors (Washington, D.C.: Apr. 2002).




              Page 25                                                GAO-03-530 School Meals Safety
                      considered. As we recently reported, school districts in selected states
                      experience year-end revenue shortfalls.


                      To improve nationwide data on the frequency and causes of foodborne
Recommendations for   illness associated with the federal school meal programs, we recommend
Executive Action      that the Secretary of Health and Human Services require the Director of
                      the Centers for Disease Control and Prevention to revise the reporting
                      mechanism that states use to voluntarily report foodborne outbreaks.
                      Specifically, states should be prompted to specify whether reported
                      outbreaks involved foods served through the federal school meal
                      programs.

                      To assist schools in their efforts to purchase safer food, we recommend
                      that the Secretary of Agriculture direct the Administrator of the
                      Agricultural Marketing Service to highlight on AMS’s Web page the more
                      stringent product safety specifications USDA uses when purchasing foods
                      it donates to schools.

                      To enhance the safety of the federal breakfast and lunch programs in
                      participating school districts, we recommend that the Secretary of
                      Agriculture direct the Administrator of the Food and Nutrition Service to
                      further promote training and certification of key school food service
                      personnel in food safety practices by, for example, publicizing the range of
                      food safety training and certification opportunities available to school
                      food service personnel from ASFSA, the National Restaurant Association,
                      and other sources.

                      To reduce the risk of bacterial contamination of food products USDA
                      donates to schools, we recommend that the Secretary of Agriculture direct
                      the Administrators of the Food and Nutrition Service and the Agricultural
                      Marketing Service to study the advantages and disadvantages, including
                      costs, of USDA donating only precooked or irradiated meat and poultry
                      products to schools. Depending on the results of the study, the Secretary
                      should consider whether to adopt these practices.


                      We provided HHS and USDA with a draft of this report for their review
Agency Comments       and comment. HHS provided written comments and agreed with our
and Our Evaluation    recommendation. Specifically, HHS said that CDC is amenable to changing
                      the outbreak reporting mechanism since many state health officials told us
                      that they are willing to collect and report additional information on the



                      Page 26                                         GAO-03-530 School Meals Safety
source of foods implicated in school-related foodborne outbreaks. HHS’s
comments are presented in appendix V.

USDA’s Deputy Administrator for Special Nutrition Programs provided us
with the agency’s oral comments on April 15, 2003. USDA generally agreed
with the report’s contents and recommendations. In addition, USDA
officials from the Agricultural Marketing Service, the Food and Nutrition
Service, and the Food Safety and Inspection Service provided technical
comments to enhance the clarity of the report. In particular, the officials
wanted us to ensure that the report is clear regarding the scope of our
survey and that its results cannot be projected. We have made
modifications to address this concern. The officials also noted that
improper food handling and poor worker hygienic practices are
responsible for many outbreaks and that food contaminated prior to
delivery to schools was found in a minority of outbreaks. We concur with
this technical comment. As our report clearly states, the results of our
survey indicate that food handling is a leading cause of foodborne
outbreaks. Finally, the officials commented that irradiating meat products
could add to the cost of these products, depending upon market
conditions and diverse factors. They noted however that additional
program funding, industry subsidies, or other factors could prevent any
such cost increases or decreases in the amount of USDA-donated
commodity. Our report acknowledges that additional costs would be
involved and recommends that USDA study the advantages and
disadvantages, including costs, of donating only precooked or irradiated
meat and poultry products to schools.

We conducted our review from August 2002 through April 2003 in
accordance with generally accepted government auditing standards.
Appendix I contains the details of our scope and methodology.


As agreed with your offices, unless you publicly announce the contents of
this report earlier, we plan no further distribution until 30 days from the
report date. We will send copies of this report to congressional
committees with jurisdiction over food safety programs; the Secretaries of
Agriculture and Health and Human Services; the Director, Office of
Management and Budget; and other interested parties. We will also make
copies available to others upon request. In addition, the report will be
made available at no charge on the GAO Web site at http://www.gao.gov.




Page 27                                        GAO-03-530 School Meals Safety
If you have any questions about this report, please contact
Maria Cristina Gobin or me at (202) 512-3841. Key contributors to this
report are listed in appendix VI.




Lawrence J. Dyckman
Director, Natural Resources
 and Environment




Page 28                                        GAO-03-530 School Meals Safety
             Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


             To determine the frequency and causes of foodborne illness associated
             with foods served through the federal school meal programs, we surveyed
             state health officials using a Web-based survey. We focused on state health
             officials because they are typically involved in the initial investigation and
             subsequent reporting to the Centers for Disease Control and Prevention
             (CDC) of foodborne outbreaks and are, therefore, able to provide more
             detailed information. The objectives of our survey were to determine
             (1) whether outbreaks listed by CDC were attributed to the federal school
             meal programs and (2) the feasibility of modifying CDC’s Foodborne
             Disease Outbreak Surveillance System to gather more specific data about
             outbreaks associated with the school meal programs. Regarding the first
             survey objective, we asked state health officials in 32 states about
             97 outbreaks, each of which, according to CDC’s surveillance system,
             involved 50 or more individuals and occurred in schools between 1990 and
             1999. Of the 97 outbreaks included in the survey, we excluded some from
             our analysis for the following reasons: states did not respond to our
             inquiries about 3 outbreaks; states responded but lacked sufficient
             information to answer questions about 22 outbreaks; and states reported
             that, according to their records, 13 outbreaks involved fewer than
             50 individuals. The remaining 59 outbreaks in 25 states formed the basis of
             our analysis.1 Because the outbreaks included in the survey are not a
             representative sample, results of the first part of the survey cannot be
             generalized. Regarding the second survey objective, to determine the
             views of all states on potential changes to the CDC reporting system, we
             also contacted officials in the 19 states and the District of Columbia that
             were not included in or did not respond to the Web survey and asked
             questions about the modification of the surveillance system identical to
             those in the second part of survey. To obtain perspective on our survey
             results, we reviewed relevant CDC studies that addressed the cause of
             foodborne outbreaks in schools in general and a FDA study that addressed
             the risk factors that contributed to foodborne illness in elementary
             schools. Lastly, we discussed with CDC officials and other food safety
             experts how CDC data limitations impact food safety assessments of the




             1
              To simplify the analysis and presentation of outbreak causes, we defined “improper food
             preparation and handling practices” as including survey responses of improper food
             storage, improper food handling, inadequate cooking, poor food worker hygiene, ill food
             workers preparing food, improper hot-holding of foods, and improper cooling of foods.




             Page 29                                                 GAO-03-530 School Meals Safety
Appendix I: Scope and Methodology




federal school meal programs.2 See appendix II for further information
about our survey.

To provide additional information about foodborne illness outbreaks in
general and to put school outbreaks into context, we examined data from
all foodborne illness outbreaks that were reported to the CDC Foodborne
Disease Outbreak Surveillance System from 1973 through 1999. We used
these data to compare the frequency and magnitude of school outbreaks to
those of outbreaks occurring in other locations. We also examined the
variability of reporting practices across states. Our analysis of CDC data is
presented in appendix III.

To identify the types of practices that federal, state, and local governments
and private sector or nonschool meal providers have in place to protect
against contamination of meals, we contacted 14 school districts, 8 state
education or health departments, 4 local health departments, and 5 private
sector or nonschool meal providers regarding their useful practices in
food safety and/or security. We chose the school districts and other
entities in consultation with several school food safety experts, including
the American School Food Service Association (ASFSA) and federal
school meal program officials from each of the 7 Food and Nutrition
Service (FNS) regional offices. Using their recommendations, we
identified and selected school districts with known useful food safety
practices or food safety challenges. In making our selection, we
considered district size, locale (rural, urban, or suburban), geographic
location, and method(s) of meal preparation (central kitchen, satellite
operations, or use of a food service management company). We conducted
on-site reviews of schools’ food safety and security practices at 11 school
districts in 7 states—Illinois, Maryland, New York, Ohio, Rhode Island,
Virginia, and Washington3—and the District of Columbia. At each location,
we discussed efforts and challenges in food safety practices with school
food authority officials and/or food service site managers. We discussed
state operations and activities with officials in Ohio, Minnesota, Rhode
Island, Washington, and the District of Columbia. To validate the useful


2
 The following limitations in CDC data make assessment of food safety in the federal
school meal programs difficult: foodborne illness outbreaks are generally underreported,
outbreak reporting practices vary among states because reporting is optional, and CDC’s
category of school does not distinguish separately federal school meals and also includes
colleges and universities.
3
 We also contacted school districts in Florida and North Carolina to discuss food safety
practices.




Page 30                                                   GAO-03-530 School Meals Safety
Appendix I: Scope and Methodology




practices and challenges identified from our site visits, we also spoke with
several food safety experts and advocates—ASFSA, the Center for Science
in the Public Interest, the Conference for Food Protection, the Consumer
Federation of America, Kids First,4 Marler Clark,5 the National Food
Service Management Institute, the National Restaurant Association,
Physicians Committee for Responsible Medicine, Resources for the
Future, and Safe Tables Our Priority.6

To identify practices that other meal service-providing entities use to
safeguard food that could be applicable to the federal school meal
programs, and to validate the useful practices and challenges identified
from our school site visits, we contacted several private sector or
nonschool meal providers—Chef America, Jack in the Box, Sodexho,7 the
Veterans Health Administration, and Walt Disney World. We also
contacted two healthcare organizations—the American Dietetic
Association and the Joint Commission on Accreditation of Healthcare
Organizations—to learn about policies these organizations use or suggest
to safeguard the health of populations most vulnerable to foodborne
illness. We selected these private sector or nonschool meal providers and
other entities to obtain a wide range of useful food safety and security




4
Kids First is a public/private partnership to improve health, nutrition, and education in
Rhode Island school systems.
5
 Marler Clark is a law firm with extensive experience in representing victims of foodborne
illness.
6
 Safe Tables Our Priority, a nonprofit organization, is devoted to assisting victims of
foodborne illnesses, and providing public education and policy advocacy in safe food and
public health.
7
 Sodexho, a food service management company, provides food and facilities management
services to over 400 school districts.




Page 31                                                   GAO-03-530 School Meals Safety
Appendix I: Scope and Methodology




practices, and we discussed with these entities their practices’ potential
applicability to the federal school meal programs. However, we did not
independently evaluate these private sector or nonschool meal provider
food safety practices. We also spoke with the private food safety experts
and advocacy groups listed previously to further identify useful private
sector food safety and security practices.




Page 32                                         GAO-03-530 School Meals Safety
              Appendix II: State Health Departments’
Appendix II: State Health Departments’
              Survey Results



Survey Results

              To determine the frequency and causes of reported foodborne illness
              outbreaks associated with the federal school meal programs, we surveyed
              state health officials using a Web-based survey. This survey was divided
              into two parts. The objective of the first part of the survey was to gain
              additional information about school foodborne illness outbreaks involving
              50 or more individuals between 1990 and 1999. Each survey addressed a
              single outbreak; thus, some states completed surveys for more than one
              outbreak. Of the 97 outbreaks included in our survey, 38 were excluded
              from analysis for the reasons described in appendix I. Results from the
              remaining 59 outbreaks are summarized herein. Though these survey
              results provide information on school foodborne illness outbreaks that
              affected 50 or more people, they are not a representative sample and are
              not projectable. The objective of the second part of the survey was to
              determine the feasibility of modifying CDC’s Foodborne Disease Outbreak
              Surveillance System to gather more specific data about outbreaks
              associated with the federal school meal programs. For more information
              about the survey methodology, see appendix I.

              The following summarizes the questions asked and the answers provided
              by the relevant state health officials that were able to provide details for
              the 59 outbreaks included in the first part of the survey. According to the
              survey respondents, 40 of the 59 outbreaks involved foods served through
              the federal school meal programs. The 40 school meal outbreaks described
              in this report are a subset of these data. The results of question 1 below
              have been recoded based on follow-up contacts with state health officials
              and our review of the completed surveys. Therefore, the response
              categories included for question 1 are different than those in the original
              survey.




              Page 33                                        GAO-03-530 School Meals Safety
                                              Appendix II: State Health Departments’
                                              Survey Results




                                              Food from the      Coded as school meal         Coded as school
                                             federal school        based on telephone       meal based on GAO
                                             meal programs                   followup                 analysis    Not a school meal

1. What was the source of the
foodborne illness outbreak? n=59                           8                           23                    9                   19




2. How many cases of illness, confirmed and
nonconfirmed, are believed to have resulted from this          Responses ranged from 50 to 400, with a mean of 130 and a median of
outbreak? n=59                                                 100.




                                                                                          Suspected but
                                                                                       not lab confirmed            Not
3. To what extent, if at all, have each of                          Epidemiologically                 or     suspected
the following foods been linked to the           Laboratory            linked/not lab- epidemiologically       to cause   No answer/
cause of the outbreak? n=59                       confirmed                confirmed              linked      outbreak    don’t know

Meat and/or meat dishes                                    8                           8                 3           24              16

Poultry and/or poultry dishes                              2                           2                 1           38              16

Fish/seafood                                               0                           0                 0           42              17

Eggs or egg products                                       0                           0                 0           40              19

Fruits/vegetables                                          0                           8                 0           36              15

Dairy                                                      0                           2                 3           37              17

Baked goods                                                0                           4                 0           37              18

Pre-prepared foods (such as frozen
entrees)                                                   0                           2                 0           38              19

Combined foods (such as casseroles,
sandwiches, or pizza)                                      2                           8                 3           28              18

Other                                                      2                           6                 2           23              26




                                              The following three items describe responses for all 59 outbreaks
                                              involving 50 or more individuals.



                                              Page 34                                               GAO-03-530 School Meals Safety
                                           Appendix II: State Health Departments’
                                           Survey Results




                                                                            No, but there is strong epidemiological support
                                                                  Yes (a)     for suspecting a specific causative agent (b)    No

4a. Was the agent suspected to have caused the
outbreak isolated from the food? n=59                                 12                                                34     13




5a. If you selected answers (a) or (b), that there was at least strong epidemiological support for
suspecting a specific causative agent, please indicate which agent is suspected. n=46                        Number of outbreaks

Salmonella (non-typhoidal)                                                                                                       4

Salmonella Enteritidis                                                                                                           2

Listeria                                                                                                                         0

Shigella                                                                                                                         2

Clostridium perfringens                                                                                                          5

Bacillus cereus                                                                                                                  1

E. coli O157:H7                                                                                                                  0

E. coli (other)                                                                                                                  0

Staphylococcal food poisoning                                                                                                    8

Campylobacter                                                                                                                    0

Norwalk or Norwalk-like virus                                                                                                  16

Other (Narrative responses included 2 outbreaks of hepatitis A)                                                                  7

No answer                                                                                                                        1




6a. What is/are the suspected underlying cause(s) of the outbreak? (Respondents were
allowed to select more than one cause.) n=59                                                                 Number of outbreaks

Food contaminated prior to delivery to school                                                                                  10

Contamination from children handling food at school                                                                              1

Inadequate cooking at school                                                                                                     7




                                           Page 35                                                  GAO-03-530 School Meals Safety
                                          Appendix II: State Health Departments’
                                          Survey Results




6a. What is/are the suspected underlying cause(s) of the outbreak? (Respondents were
allowed to select more than one cause.) n=59                                                             Number of outbreaks

Improper food storage at school                                                                                            13

Improper food handling at school                                                                                             9

Poor food worker hygiene at school                                                                                         13

Food worker illness at school                                                                                                5

Improper hot holding at school                                                                                             10

Improper cooling at school                                                                                                   5

Insect/rodent contamination at school                                                                                        0

Other suspected cause at school (please specify)                                                                             7

Unknown                                                                                                                    19




                                          The following three items repeat the previous, but focus on the 40
                                          outbreaks that involved federal school meals.

                                                           Yes      No, but there is strong epidemiological support for
                                                            (a)               suspecting a specific causative agent (b)    No

4b. Was the agent suspected to have caused the
outbreak isolated from the food? n=40                         8                                                     25       7




5b. If you selected answers (a) or (b), that there was at least strong epidemiological support for                 Number of
suspecting a specific causative agent, please indicate which agent is suspected. n=33                              outbreaks

Salmonella (non-typhoidal)                                                                                                   4

Salmonella Enteritidis                                                                                                       1

Listeria                                                                                                                     0

Shigella                                                                                                                     2

Clostridium perfringens                                                                                                      4




                                          Page 36                                               GAO-03-530 School Meals Safety
                                           Appendix II: State Health Departments’
                                           Survey Results




5b. If you selected answers (a) or (b), that there was at least strong epidemiological support for                 Number of
suspecting a specific causative agent, please indicate which agent is suspected. n=33                              outbreaks

Bacillus cereus                                                                                                              1

E. coli O157:H7                                                                                                              0

E. coli (other)                                                                                                              0

Staphylococcal food poisoning                                                                                                7

Campylobacter                                                                                                                0

Norwalk or Norwalk-like virus                                                                                                8

Other (Narrative responses included 2 outbreaks of hepatitis A)                                                              5

No answer                                                                                                                    1




6b. What is/are the suspected underlying cause(s) of the outbreak? (Respondents were allowed to                    Number of
select more than one cause.) n=40                                                                                  outbreaks

Food contaminated prior to delivery to school                                                                                8

Contamination from children handling food at school                                                                          0

Inadequate cooking at school                                                                                                 4

Improper food storage at school                                                                                            11

Improper food handling at school                                                                                             8

Poor food worker hygiene at school                                                                                         11

Food worker illness at school                                                                                                4

Improper hot holding at school                                                                                               6

Improper cooling at school                                                                                                   5

Insect/rodent contamination at school                                                                                        0

Other suspected cause at school (please specify)                                                                             0

Unknown                                                                                                                    13




                                           Page 37                                              GAO-03-530 School Meals Safety
                                         Appendix II: State Health Departments’
                                         Survey Results




                                         The following summarizes the results of the second half of the survey.
                                         These results include the 31 states that responded to the Web-based
                                         survey and the 19 states plus the District of Columbia that we contacted,
                                         totaling 51 respondents.

                                                                                                  Could obtain information if
                                                                                                                            a
                                                                                          Yes                        asked             No
 7. In the section asking, “Where was the food eaten?” under the selection
 “school,” if a subcategory of “federal school meal” was added, would you
 usually have the information needed to answer this question? n=51                         32                                  14        5
 8. In the section asking “Where was the food prepared?” under the selection
 “school,” if a subcategory of “federal school meal” was added, would you
 usually have the information needed to answer this question? n=51                         32                                  14        5

Source: GAO.
                                         a
                                          We included this option in the telephone survey but not in the Web-based survey. Respondents from
                                         the Web-based survey were included in this category if their comments in the open-ended “further
                                         explanation” portion of the question stated that they could obtain the information if asked.




                                         Page 38                                                       GAO-03-530 School Meals Safety
              Appendix III: GAO’s Analysis of CDC Data
Appendix III: GAO’s Analysis of CDC Data


              Using data from the CDC’s Foodborne Disease Outbreak Surveillance
              System, we examined patterns in foodborne illness outbreaks in general
              and in school outbreaks in particular. We examined data covering the time
              period from 1973 through 1999, the last year for which complete outbreak
              data were available at the time of our review. Table 1 shows the total
              number of outbreaks, and the numbers of illnesses, hospitalizations, and
              deaths associated with them, that were reported over the entire period.
              Figure 2 shows the total number of reported outbreaks, and figure 3 shows
              the total number of illnesses.

              Table 2 shows the number of reported outbreaks that resulted from foods
              in restaurants, private homes, schools, and other locations. It is important
              to note that this analysis does not identify foods that are served through
              the federal school meal programs. Overall, 4 percent of the outbreaks
              resulted from foods in schools; 54 percent from food prepared in
              restaurants; 15 percent resulted from foods in private homes; and
              23 percent from foods in other locations, including churches, caterers,
              grocery stores, nursing homes, and a broad array of other locations. For
              about 5 percent of the reported outbreaks, the location was unknown. The
              percentage of outbreaks attributable to foods in schools fluctuated
              between 2.3 percent and 5 percent across the various 3-year intervals. As
              data supporting figure 4 show, the number of school outbreaks over the
              entire period follows a trend similar to the trends in outbreaks resulting
              from foods in restaurants and in private homes—that is, the numbers
              increased for all three groups of outbreaks between the early and late
              1990s. Outbreaks resulting from foods prepared in the other locations
              increased somewhat more linearly over the entire period.

              Interestingly, CDC data show that food outbreaks at schools involve larger
              numbers of illnesses than outbreaks that occur in other locations. Table 3
              shows that over the entire period, the 547 reported outbreaks resulting
              from foods in schools produced 46,461 reported illnesses, approximately
              10 percent of all illnesses. While each school outbreak caused 85 illnesses
              on average, each outbreak associated with foods from restaurants and
              private homes caused an average of 18 and 13 illnesses, respectively. Only
              the category of “other” outbreaks, which caused an average of 56 illnesses,
              approached the average number of illnesses associated with school
              outbreaks, most likely because many of the other outbreaks involve
              institutionalized populations (nursing homes, universities, prisons, etc.) as
              well. Similarly, school outbreaks tend to comprise a greater number of
              large outbreaks when we distinguish large outbreaks (involving 50 or more
              illnesses) from smaller ones. As the final column of table 3 shows,
              51 percent of the school outbreaks over the entire period were large,


              Page 39                                         GAO-03-530 School Meals Safety
Appendix III: GAO’s Analysis of CDC Data




compared with 7 percent of the restaurant-related outbreaks, 4 percent of
the private home-related outbreaks, 25 percent of the other outbreaks, and
10 percent of the outbreaks of unknown origin.

In general, identifying the frequency and causes of school outbreaks in
CDC’s data is difficult because reporting of outbreaks to CDC is voluntary,
and the reporting practices of states vary. In table 4, we show the number
of outbreaks reported by each state over the entire period, classified
according to where the food that produced the outbreak was prepared.
The row totals reveal dramatic differences across states in the number of
outbreaks reported over this 27-year period. Some states, like Delaware,
Mississippi, Nevada, South Dakota, and Wyoming, reported fewer than
30 outbreaks in total, or only about 1 outbreak per year. Other states, like
California, Florida, and Washington, reported over 1,000 outbreaks in the
period, and New York reported over 3,000. States also differed in the
locations in which their reported outbreaks occurred. While some states
reported 20 or more school outbreaks in the 27-year period, other states
reported only 1 or 2. Similar disparities exist across states in the
percentage of outbreaks resulting from restaurant foods (ranging from
8 percent in Alaska to 73 percent in Washington) and in the percentage of
outbreaks resulting from foods prepared in private homes (ranging from
4 percent in Arkansas to 50 percent in Alaska).

Some of these discrepancies may be due to differences among states in
population and in such characteristics as the number of restaurants and
the eating habits of residents. However, these differences in the number of
reported outbreaks persist even after differences in population are crudely
controlled. In table 5, we show the number of outbreaks over the entire
period as a function of population size by dividing the number of
outbreaks by the population of each state averaged from the 1970, 1980,
1990, and 2000 Censuses. The rate of outbreaks per 100,000 individuals
during the 27-year period ranged from only 1 or 2 per 100,000 in some
states to nearly 20, 30, or more than 60 per 100,000 in others. These data
demonstrate that states with the largest number of reported outbreaks are
not necessarily those with the largest populations. Moreover, the patterns
in the 5 states reporting the largest numbers of outbreaks (see table 6 and
figure 5) are extremely disparate. While the increase in the number of
outbreaks in Ohio and the sizable decrease in the number of outbreaks in
New York since the early 1980s may reflect declines or improvements in
food handling or preparation in each state over time, these outbreak




Page 40                                         GAO-03-530 School Meals Safety
Appendix III: GAO’s Analysis of CDC Data




patterns probably also involve changes in how each state reports
foodborne outbreaks.1

After we completed our analysis, CDC published foodborne outbreak data
for 2000 on its website. In 2000, 67 of the 1,413 reported outbreaks
occurred in schools. These 67 outbreaks caused 2,987 illnesses. However,
the 2000 data are not comparable to the numbers of school outbreaks
discussed elsewhere in this report, because we refined the 1973 through
1999 data to exclude, for example, colleges and universities.

Table 1: Number of Reported Foodborne Outbreaks and Related Illnesses,
Hospitalizations, and Deaths, 1973-1999

    Year                      Outbreaks      Illnesses      Hospitalizations            Fatalities
    1973-75                       1,260          48,537                1,906                    41
    1976-78                       1,393          34,357                1,833                    21
    1979-81                       1,739          43,057                2,177                    66
    1982-84                       1,712          51,159                2,086                    76
    1985-87                       1,381          63,004                4,328                    94
    1988-90                       1,489          50,830                2,349                    57
    1991-93                       1,456          40,215                1,735                    31
    1994-96                       1,937          45,913                1,692                    21
    1997-99                       3,464          70,411                2,013                    47
    Total                        15,831        447,483                20,119                  457
Source: GAO analysis of CDC data.

Note: The number of illnesses were reported for all outbreaks, though for 1 outbreak no illnesses
were reported, and for 326 (2.1 percent) of the outbreaks only one illness was reported. The number
of hospitalizations were not reported for 3,379 (21.3 percent) of the 15,831 outbreaks, and the
number of fatalities were not reported for 2,638 (16.7 percent) of the 15,831 outbreaks.




1
 Outbreaks in Ohio increased from 15 outbreaks (1982-1984) to 287 outbreaks (1997-1999).
Outbreaks in New York decreased from 658 outbreaks (1982-1984) to 204 outbreaks (1997-
1999).




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Appendix III: GAO’s Analysis of CDC Data




Table 2: Number of Reported Foodborne Outbreaks Resulting from Foods Prepared
in Restaurants, Private Homes, Schools, and in Other Locations, 1973-1999

                                         Private
 Year           Restaurants              homes     Schools       Other    Unknown            Total
 1973-75                494                  397         56         258          55          1,260
                     39.2%                31.5%       4.4%       20.5%        4.4%         100.0%
 1976-78                729                  279         56         259          70          1,393
                     52.3%                20.0%       4.0%       18.6%        5.0%         100.0%
 1979-81                969                  288         87         339          56          1,739
                     55.7%                16.6%       5.0%       19.5%        3.2%         100.0%
 1982-84                876                  333         63         396          44          1,712
                     51.2%                19.5%       3.7%       23.1%        2.6%         100.0%
 1985-87                715                  221         59         320          66          1,381
                     51.8%                16.0%       4.3%       23.2%        4.8%         100.0%
 1988-90                736                  196         51         451          55          1,489
                     49.4%                13.2%       3.4%       30.3%        3.7%         100.0%
 1991-93                766                  186         36         433          35          1,456
                     52.6%                12.8%       2.5%       29.7%        2.4%         100.0%
 1994-96               1160                  221         45         466          45          1,937
                     59.9%                11.4%       2.3%       24.1%        2.3%         100.0%
 1997-99               2020                  283         94         782        285           3,464
                     58.3%                 8.2%       2.7%       22.6%        8.2%         100.0%
 Total                8,465                2,404       547        3,704        711          15,831
                     53.5%                15.2%       3.5%       23.4%        4.5%         100.0%
Source: GAO analysis of CDC data.

Note: Restaurants include delicatessens and cafeterias. For our analysis, we excluded universities
and colleges from the schools category. The other category includes churches, caterers, grocery
stores, nursing homes, camps, and prisons.




Table 3: Number of Illnesses Associated with Reported Foodborne Outbreaks
Resulting from Foods Prepared in Restaurants, Private Homes, Schools, and in
Other Locations, 1973-1999

 Location of                                                                       Percent of
 food                                                            Illnesses per outbreaks with
 preparation                        Outbreaks       Illnesses         outbreak  50+ illnesses
 Restaurant                             8,465         148,548             17.5           7.3%
 Private home                           2,404           30,198            12.6           3.8%
 School                                   547           46,461            84.9          50.5%
 Other                                  3,704         207,191             55.9          25.0%
 Unknown                                  711           15,085            21.2           9.8%
 Total                                 15,831         447,483             28.3          12.5%
Source: GAO analysis of CDC data.




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                                       Appendix III: GAO’s Analysis of CDC Data




Table 4: Number of Illnesses Associated with Reported Foodborne Outbreaks Resulting from Foods Prepared in Restaurants,
Private Homes, Schools, and in Other Locations, by State, 1973-1999

State                  Restaurant           Home              School              Other      Unknown                Total
Alaska                         11               68                  2                 27            29                137
                            8.0%            49.6%               1.5%              19.7%         21.2%             100.0%
Alabama                        90               15                 12                 18             1                136
                           66.2%            11.0%               8.8%              13.2%           .7%             100.0%
Arkansas                        8                1                  3                 13             0                 25
                           32.0%             4.0%              12.0%              52.0%            0%             100.0%
Arizona                        37               21                  7                 35             3                103
                           35.9%            20.4%               6.8%              34.0%          2.9%             100.0%
California                    533             231                  27               305             61              1,157
                           46.1%            20.0%               2.3%              26.4%          5.3%             100.0%
Colorado                       59               21                  2                 33             4                119
                           49.6%            17.6%               1.7%              27.7%          3.4%             100.0%
Connecticut                   102               41                 21                 89             8                261
                           39.1%            15.7%               8.0%              34.1%          3.1%             100.0%
District of                    15                2                  4                 11             0                 32
Columbia
                           46.9%             6.3%              12.5%              34.4%             0%            100.0%
Delaware                        8                3                  2                 13              1                27
                           29.6%            11.1%               7.4%              48.1%           3.7%            100.0%
Florida                      675              122                  28               181              33             1,039
                           65.0%            11.7%               2.7%              17.4%           3.2%            100.0%
Georgia                        64               22                 24                 45              8               163
                           39.3%            13.5%              14.7%              27.6%           4.9%            100.0%
Hawaii                       215              316                   6                 89             43               669
                           32.1%            47.2%                .9%              13.3%           6.4%            100.0%
Iowa                           48               20                  3                 26              2                99
                           48.5%            20.2%               3.0%              26.3%           2.0%            100.0%
Idaho                          42               17                  1                 18              4                82
                           51.2%            20.7%               1.2%              22.0%           4.9%            100.0%
Illinois                     292                61                 22               176              12               563
                           51.9%            10.8%               3.9%              31.3%           2.1%            100.0%
Indiana                        43                8                  3                 40              5                99
                           43.4%             8.1%               3.0%              40.4%           5.1%            100.0%
Kansas                         30                6                  6                 16              3                61
                           49.2%             9.8%               9.8%              26.2%           4.9%            100.0%
Kentucky                       23               15                  3                 20              7                68
                           33.8%            22.1%               4.4%              29.4%          10.3%            100.0%
Louisiana                      15               20                  9                 33              6                83
                           18.1%            24.1%              10.8%              39.8%           7.2%            100.0%
Massachusetts                133                28                 25               118              19               323
                           41.2%             8.7%               7.7%              36.5%           5.9%            100.0%




                                       Page 43                                             GAO-03-530 School Meals Safety
                              Appendix III: GAO’s Analysis of CDC Data




State            Restaurant        Home              School              Other      Unknown                Total
Maryland                341            47                  7               105             15                515
                     66.2%          9.1%               1.4%              20.4%          2.9%             100.0%
Maine                    37             6                  2                 30             1                 76
                     48.7%          7.9%               2.6%              39.5%          1.3%             100.0%
Michigan                236            21                 16                 80          100                 453
                     52.1%          4.6%               3.5%              17.7%         22.1%             100.0%
Minnesota               204            53                 19               131             11                418
                     48.8%         12.7%               4.5%              31.3%          2.6%             100.0%
Missouri                 78            13                 17                 47             3                158
                     49.4%          8.2%              10.8%              29.7%          1.9%             100.0%
Mississippi              10             3                  2                 10             0                 25
                     40.0%         12.0%               8.0%              40.0%            0%             100.0%
Montana                  12             7                  2                  7            13                 41
                     29.3%         17.1%               4.9%              17.1%         31.7%             100.0%
North Carolina           44             5                  6                 46             4                105
                     41.9%          4.8%               5.7%              43.8%          3.8%             100.0%
North Dakota             14            12                  4                 10             4                 44
                     31.8%         27.3%               9.1%              22.7%          9.1%             100.0%
Nebraska                 26            12                  2                 19             1                 60
                     43.3%         20.0%               3.3%              31.7%          1.7%             100.0%
New Hampshire            21             3                 10                 22             2                 58
                     36.2%          5.2%              17.2%              37.9%          3.4%             100.0%
New Jersey              143            45                 13               103             17                321
                     44.5%         14.0%               4.0%              32.1%          5.3%             100.0%
New Mexico               52            24                  8                 23             7                114
                     45.6%         21.1%               7.0%              20.2%          6.1%             100.0%
Nevada                   13             4                  0                  8             4                 29
                     44.8%         13.8%                 0%              27.6%         13.8%             100.0%
New York              2,095          349                  72               636             67              3,219
                     65.1%         10.8%               2.2%              19.8%          2.1%             100.0%
Ohio                    463          103                  21               144             20                751
                     61.7%         13.7%               2.8%              19.2%          2.7%             100.0%
Oklahoma                 22            15                  5                 19             3                 64
                     34.4%         23.4%               7.8%              29.7%          4.7%             100.0%
Oregon                   69            44                 10                 41            24                188
                     36.7%         23.4%               5.3%              21.8%         12.8%             100.0%
Pennsylvania            305          154                  24               207             33                723
                     42.2%         21.3%               3.3%              28.6%          4.6%             100.0%
Rhode Island              8            10                  5                  8             2                 33
                     24.2%         30.3%              15.2%              24.2%          6.1%             100.0%
South Carolina           33            13                  2                 17             2                 67
                     49.3%         19.4%               3.0%              25.4%          3.0%             100.0%
South Dakota             10             6                  1                  5             0                 22
                     45.5%         27.3%               4.5%              22.7%            0%             100.0%




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                                                  Appendix III: GAO’s Analysis of CDC Data




 State                              Restaurant         Home               School             Other         Unknown                Total
 Tennessee                                  45             18                   8                27                2                100
                                        45.0%          18.0%                8.0%             27.0%             2.0%             100.0%
 Texas                                     104             25                  15                53               43                240
                                        43.3%          10.4%                6.3%             22.1%            17.9%             100.0%
 Utah                                       22             25                   3                 9                0                 59
                                        37.3%          42.4%                5.1%             15.3%               0%             100.0%
 Virginia                                   94             37                  13                80               11                235
                                        40.0%          15.7%                5.5%             34.0%             4.7%             100.0%
 Vermont                                    23             10                  11                34                0                 78
                                        29.5%          12.8%               14.1%             43.6%               0%             100.0%
 Washington                              1,233            175                  13               238               39              1,698
                                        72.6%          10.3%                 .8%             14.0%             2.3%             100.0%
 Wisconsin                                 217             53                  20               134               15                439
                                        49.4%          12.1%                4.6%             30.5%             3.4%             100.0%
 West Virginia                               5             10                   3                12                1                 31
                                        16.1%          32.3%                9.7%             38.7%             3.2%             100.0%
 Wyoming                                     5              5                   2                 2                0                 14
                                        35.7%          35.7%               14.3%             14.3%               0%             100.0%
 Total                                   8,427          2,345                546              3,613             693              15,624
                                        53.9%          15.0%                3.5%             23.1%             4.4%             100.0%
Source: GAO analysis of CDC data.



Table 5: Reported Foodborne Outbreaks Per 100,000 Population, by State, 1973-1999

                                                                                                                         Outbreaks per
                                                                      a
 State                                           Averaged population                         Outbreaks              100,000 population
 Alaska                                                       470,352                              137                            29.1
 Alabama                                                    3,956,482                              136                             3.4
 Arkansas                                                   2,308,471                               25                             1.1
 Arizona                                                    3,322,369                              103                             3.1
 California                                                26,817,660                            1,157                             4.3
 Colorado                                                   3,173,804                              119                             3.8
 Connecticut                                                3,208,119                              261                             8.1
 District of Columbia                                         643,490                               32                             5.0
 Delaware                                                     648,053                               27                             4.2
 Florida                                                   11,364,512                            1,039                             9.1
 Georgia                                                    6,178,926                              163                             2.6
 Hawaii                                                     1,013,593                              669                            66.0
 Iowa                                                       2,860,564                               99                             3.5
 Idaho                                                        989,413                               82                             8.3
 Illinois                                                  11,596,675                              563                             4.9
 Indiana                                                    5,577,565                               99                             1.8
 Kansas                                                     2,444,686                               61                             2.5
 Kentucky                                                   3,652,138                               68                             1.9
 Louisiana                                                  4,134,872                               83                             2.0



                                                  Page 45                                                GAO-03-530 School Meals Safety
                                     Appendix III: GAO’s Analysis of CDC Data




                                                                                                                    Outbreaks per
                                                            a
 State                              Averaged population                              Outbreaks                 100,000 population
 Massachusetts                                 5,947,932                                   323                                5.4
 Maryland                                      4,554,707                                   515                               11.3
 Maine                                         1,155,308                                    76                                6.6
 Michigan                                      9,344,411                                   453                                4.9
 Minnesota                                     4,294,163                                   418                                9.7
 Missouri                                      5,076,648                                   158                                3.1
 Mississippi                                   2,538,877                                    25                                1.0
 Montana                                         795,590                                    41                                5.2
 North Carolina                                6,411,032                                   105                                1.6
 North Dakota                                    637,877                                    44                                6.9
 Nebraska                                      1,586,202                                    60                                3.8
 New Hampshire                                 1,000,832                                    58                                5.8
 New Jersey                                    7,670,118                                   321                                4.2
 New Mexico                                    1,413,516                                   114                                8.1
 Nevada                                        1,122,330                                    29                                2.6
 New York                                     18,191,594                                 3,219                               17.7
 Ohio                                         10,913,827                                   751                                6.9
 Oklahoma                                      3,045,248                                    64                                2.1
 Oregon                                        2,747,090                                   188                                6.8
 Pennsylvania                                 11,956,840                                   723                                6.1
 Rhode Island                                    987,165                                    33                                3.3
 South Carolina                                3,302,812                                    67                                2.0
 South Dakota                                    701,968                                    22                                3.1
 Tennessee                                     4,770,902                                   100                                2.1
 Texas                                        15,816,544                                   240                                1.5
 Utah                                          1,619,082                                    59                                3.6
 Virginia                                      5,816,035                                   235                                4.0
 Vermont                                         531,943                                    78                               14.7
 Washington                                    4,576,553                                 1,698                               37.1
 Wisconsin                                     4,844,758                                   439                                9.1
 West Virginia                                 1,823,926                                    31                                1.7
 Wyoming                                         437,336                                    14                                3.2
Source: GAO analysis of CDC data.
                                     a
                                      Population data were obtained from the U.S. Census Bureau. Population is averaged over the 1970,
                                     1980, 1990, and 2000 Census data.




                                     Page 46                                                      GAO-03-530 School Meals Safety
Appendix III: GAO’s Analysis of CDC Data




Table 6: Number of Reported Foodborne Outbreaks in Five States Reporting the
Largest Numbers, 1973-1999

 Year               California      Florida   New York   Ohio   Washington        Total
 1973-75                   111           47        155     22          148          483
 1976-78                   120           25        380     13          143          681
 1979-81                   128           52        530     43          163          916
 1982-84                   104           49        658     15          125          951
 1985-87                   100           27        410     19          162          718
 1988-90                    35           45        335     59          107          581
 1991-93                    95           38        297     61          221          712
 1994-96                   176          140        250    232          381        1179
 1997-99                   288          616        204    287          248        1643
 Total                   1,157        1,039      3,219    751        1,698        7,864
Source: GAO analysis of CDC data.




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Figure 2: Total Number of Reported Outbreaks, 1973-1999

Number of reported outbreaks
4,000

                                                                                     3,464


3,000




2,000                                                                        1,937
                                    1,739   1,712
                                                            1,489    1,456
                     1,393                          1,381
         1,260

1,000




    0
         1973-       1976-          1979-   1982-   1985-   1988-    1991-   1994-   1997-
         1975        1978           1981    1984    1987    1990     1993    1996    1999
        Year
Source: GAO analysis of CDC data.




Note: For 1997-1999, CDC attributes much of the increases in reported outbreaks to improved data
collection procedures initiated in 1998.




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Figure 3: Total Number of Illness Associated with Reported Outbreaks, 1973-1999


Number of reported illnesses
80,000

                                                                                           70,411
70,000
                                                      63,004
60,000

                                             51,159            50,830
50,000    48,537
                                                                                  45,913
                                    43,057
                                                                         40,215
40,000
                      34,357

30,000


20,000


10,000


      0
           1973-       1976-        1979-    1982-    1985-    1988-      1991-   1994-    1997-
           1975        1978         1981     1984     1987     1990       1993    1996     1999
          Year
Source: GAO analysis of CDC data.

Note: For 1997-1999, CDC attributes some of the increases in reported outbreaks to improved data
collection procedures initiated in 1998.




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Appendix III: GAO’s Analysis of CDC Data




Figure 4: Number of Reported Outbreaks, by Where Food Was Prepared, 1973-1999

Number of outbreaks
2,500




2000




1,500




1,000




  500




    0
     1973-        1976-             1979-   1982-   1985-   1988-     1991-       1994-      1997-
     1975         1978              1981    1984    1987    1990      1993        1996       1999
        Year

                  Restaurant
                  Private home
                  School
                  Other
Source: GAO analysis of CDC data.

Note: For 1997-1999, CDC attributes some of the increases in reported outbreaks to improved data
collection procedures initiated in 1998.




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Appendix III: GAO’s Analysis of CDC Data




Figure 5: Number of Outbreaks in States Reporting the Largest Number of
Outbreaks, 1973-1999


Number of outbreaks
700


600


500


400


300


200


100


  0
  1973-          1976-         1979-   1982-       1985-       1988-       1991-        1994-      1997-
   1975          1978          1981    1984        1987        1990        1993         1996       1999
        Year

                California
                Florida
                New York
                Ohio
                Washington
Source: GAO analysis of CDC data.

Note: For 1997-1999, CDC attributes some of the increases in reported outbreaks to improved data
collection procedures initiated in 1998. This figure depicts the states reporting the largest number of
outbreaks over the time period, not the states with the largest populations.




Page 51                                                           GAO-03-530 School Meals Safety
              Appendix IV: Food Safety and Security
Appendix IV: Food Safety and Security
              Practices for School Meal Programs Used or
              Suggested by Government or Private Sector


Practices for School Meal Programs Used or
Suggested by Government or Private Sector
              School districts, government agencies, and the private sector use or
              suggest useful food safety and security practices for school meal
              programs. Table 7 presents these practices, which are classified into two
              main categories—food safety and food security. For both main categories,
              the most frequently cited specific categories appears first. For example,
              for food safety the specific category of training and certification was most
              frequently cited and thus appears first. Similarly, within each category the
              most frequently cited practice appears first. Table 7 also describes the
              food safety or security benefit of each practice and indicates the type of
              entity that uses or suggests each practice. Some of the practices and
              suggestions listed in the table may not be practical for all school districts,
              especially those that are resource-constrained from either the state or
              local levels.1

              Table 7 is not intended to be an all-encompassing primer on food safety
              and security, but rather a compilation of useful practices that we observed
              or discussed with entities we contacted during our review. Some of the
              practices cited are components of larger food safety concepts. For more
              complete information on food safety, FNS suggests that interested parties
              may reference the extensive support materials prepared by the National
              Food Service Management Institute, which may be accessed at
              www.nfsmi.org. As stated earlier, appropriate security practices will be
              available in the forthcoming FNS security guidelines for schools. FNS
              believes that some of the practices as cited may not reflect the views of or
              be endorsed by national school organizations or leaders in food industry.
              Obtaining such endorsements was beyond the scope of our review.




              1
               See U.S. General Accounting Office, School Meals Programs: Revenue and Expense
              Information from Selected States, GAO-03-569 (Washington, D.C.: May 9, 2003).




              Page 52                                              GAO-03-530 School Meals Safety
                                               Appendix IV: Food Safety and Security
                                               Practices for School Meal Programs Used or
                                               Suggested by Government or Private Sector




Table 7: Food Safety and Security Practices for School Meal Programs Used or Suggested by Government or Private Sector

                                                                                                                 State and
                                                                                            School      Federal  local       Private
Useful practices and suggestions                               Benefits                     districts   agencies agencies    sector
FOOD SAFETY
1. Training and certification
Require certification of at least one food service worker in   Enhances food safety and          X          X          X         X
each school kitchen by use of established certification        establishes a standard for
programs or through self- or state-developed courses.          food safety education.
Require or provide ongoing documented training for food        Reinforces proper food            X          X          X         X
service workers in food safety topics such as controlling      safety practices and
food inventory, handling leftovers, receiving and storing      facilitates learning.
food, using written cleaning and sanitation procedures,
maintaining proper temperatures, and packaging.
Have local health department monitor certification             Enforces compliance with          X          X                    X
requirements.                                                  food safety requirements.
Use multilingual training courses and post food safety         Promotes training in and          X          X
messages in languages other than English or in graphics        understanding of food
that do not require language instruction.                      safety among all food
                                                               service workers.
Require all food safety trainers to be certified.              Establishes a standard for                                        X
                                                               food safety education.
Train workers on critical control points of HACCP at each      Facilitates food safety                                           X
food service workstation.                                      training.
Communicate importance of food safety through video            Facilitates food safety                                           X
screening that includes children who got sick from             training and reinforces
foodborne illness.                                             seriousness of impacts of
                                                               foodborne illness.
2. Risk-based food safety concepts
Mandate and document self-inspections, such as HACCP           Promotes use of risk-based        X          X          X         X
checklists provided by USDA, at each school.                   food safety procedures and
                                                               increases monitoring.

Have USDA develop and disseminate generic HACCP              Promotes use of risk-based          X          X                    X
plans for school districts, such as a template. HACCP plans food safety procedures and
would be individualized to school’s food service operations. establishes a common
                                                             standard for food safety
                                                             practices.
Use HACCP-based food safety concepts throughout school Promotes use of risk-based                X          X                    X
food service operations, such as hygiene, time and           food safety procedures and
temperature controls, prevention of cross contamination,     establishes common
documentation, training, and self-inspection.                standard for food safety
                                                             practices.

Adopt and use standardized recipes with critical control       Promotes use of risk-based        X          X          X
points.                                                        food safety procedures.




                                               Page 53                                                  GAO-03-530 School Meals Safety
                                              Appendix IV: Food Safety and Security
                                              Practices for School Meal Programs Used or
                                              Suggested by Government or Private Sector




                                                                                                                  State and
                                                                                             School      Federal  local       Private
Useful practices and suggestions                              Benefits                       districts   agencies agencies    sector
Record and/or check temperatures of refrigerators,            Helps ensure proper food            X          X          X
freezers, delivery trucks, and high-risk foods periodically   preparation, facilitates
each day, including maintaining temperature and daily         monitoring, helps detect
production records for support and satellite schools and      any spoilage due to
calibration of thermometers.                                  improper food holding, and
                                                              ensures accuracy of food
                                                              temperatures.
Provide templates for different types of food preparation,    Promotes use of risk-based                                          X
such as cooking meat, reheating foods, using prepackaged food safety procedures and
meals, and preparing salads.                                  establishes common
                                                              standard for food safety
                                                              practices.
Adopt food safety measures that exceed the current FDA Provides additional food                   X                     X
Food Code, such as maintaining temperature logs,              safety protection.
requiring double hand washing by food service workers
after they use the rest room, or heating premade or
precooked food items, such as pizza, to higher
temperatures while retaining food quality and palatability.
Require school district authorities to perform food safety    Increases monitoring of             X          X
inspections of schools twice a month or when visiting         schools’ food safety
schools.                                                      practices.
Adopt basic health standards for food service employees Minimizes risk of                                    X          X
that handle foods, such as preventing employees who are pathogens spread by ill
coughing and sneezing from working.                           workers.
Require suppliers to use HACCP plans or food safety and Decreases likelihood of                              X                    X
quality control programs in their manufacturing practices. receiving contaminated
                                                              food.
Incorporate critical control points into school lunch program Promotes food safety.                          X
recipes, which are available on Internet and CD-ROM, and
incorporate new food purchasing guidelines into recipes.
Thoroughly wash fresh produce.                                Provides additional food                                            X
                                                              protection.
3. Food storage, handling, and preparation
Require food service staff to properly use and change         Avoids exposure to any              X          X          X         X
gloves or tongs.                                              pathogens on hands.
Prohibit food deliveries at loading docks that are not        Prevents potentially                X          X                    X
supervised by authorized staff.                               contaminated/questionable
                                                              food products from entering
                                                              schools.
Develop procedures to address high-risk foods, such as        Eliminates possible                 X                               X
melons, sprouts, unpasteurized eggs, and salad bar items. sources of food
                                                              contamination and reduces
                                                              likelihood of contamination.
Require proper cooling procedures, such as breaking down Minimizes opportunities for                         X          X         X
batches of food into shallow serving pans for fast chill,     pathogen growth.
immersing wrapped foods in ice for fast cooling, or using
blast chillers.




                                              Page 54                                                    GAO-03-530 School Meals Safety
                                             Appendix IV: Food Safety and Security
                                             Practices for School Meal Programs Used or
                                             Suggested by Government or Private Sector




                                                                                                                  State and
                                                                                             School      Federal  local       Private
Useful practices and suggestions                               Benefits                      districts   agencies agencies    sector
Spot check deliveries for temperature, labeling, and           Identifies potentially                        X                    X
packaging and record results.                                  contaminated incoming
                                                               food products.
Mark dates on all delivered items and use oldest inventory Facilitates proper inventory           X          X
first.                                                         maintenance.
Require staff to wear hats or hairnets during food             Helps minimize                     X          X
preparation and/or service.                                    contamination of foods.
Use cutting boards that are color-coded by food group and Minimizes cross                                    X                    X
sanitize them after each use accordingly.                      contamination of foods.
Properly preserve portions of foods served.                    Allows later food safety           X          X
                                                               testing if problems are
                                                               suspected.
4. Nonschool meal foods
Adopt policy of discouraging or prohibiting food prepared Minimizes bringing food                 X          X          X
outside the school from being served or stored in school       into schools that is
facilities.                                                    prepared elsewhere.
Require food service staff to be present whenever school Allows proper oversight of               X          X
kitchen is used.                                               school facilities.
Cater special events from school food service facility.        Minimizes bringing food            X
                                                               into schools that is
                                                               prepared elsewhere.
5. Product procurement and menu design
Maximize use of precooked meat and poultry products.           Mitigates E. coli O157:H7          X                     X         X
                                                               and Salmonella exposure,
                                                               reduces labor costs, and
                                                               removes fat from meat and
                                                               poultry products.
Eliminate high-risk foods, such as alfalfa sprouts, medium- Reduces potential for                            X          X         X
rare hamburgers, and unpasteurized juices.                     foodborne contamination.
6. Supplier selection
Select suppliers that use HACCP or are more process            Provides criteria for              X          X                    X
control oriented (e.g., HACCP-based) and technologically selecting better quality
based.                                                         suppliers.
Allow flexibility in awarding contracts to the lowest bidder. Provides flexibility in             X          X
                                                               selecting suppliers.
Visit production facilities of all prospective food suppliers. Helps ensure that suppliers        X
                                                               use appropriate food safety
                                                               practices.
Select suppliers according to food safety performance by Provides criteria for                    X                               X
consulting past safety records, independent auditing           selecting better quality
results, supplier facility HACCP plans, microbial testing      suppliers and food
results of high risk foods and standard operating, storage products.
and recall procedures.
Select processors that are approved by USDA and state          Provides criteria for                                              X
agencies when contracting for additional processing of         selecting better quality
USDA-donated commodities.                                      suppliers.




                                             Page 55                                                     GAO-03-530 School Meals Safety
                                            Appendix IV: Food Safety and Security
                                            Practices for School Meal Programs Used or
                                            Suggested by Government or Private Sector




                                                                                                                 State and
                                                                                            School      Federal  local       Private
Useful practices and suggestions                             Benefits                       districts   agencies agencies    sector
7. Product specifications
Award supplier contracts that include food safety             Provides additional                X                     X
requirements, such as third-party microbiological testing     assurance of food quality
before foods are delivered to schools and maximum             by requiring proper food
delivery times.                                               holding temperatures and
                                                              minimizing potentially
                                                              contaminated food supplies
                                                              from entering schools.
Apply strictest of USDA, state, or local standards in         Ensures highest standards                                          X
specifications required of processing companies.              for food safety.
Make food safety-related specifications on AMS Web page Allows states and districts                         X
more user friendly.                                           to use federal procurement
                                                              expertise.
Apply AMS’s procurement specifications for donated            Enhances food safety of                       X
commodities that exceed minimum standards of regulatory school children.
agencies to schools’ commercial food purchases.
Use assistance available from AMS to school districts or      Allows states and districts                   X
states in developing contract or product specifications.      to use federal procurement
                                                              expertise.
Have state education department and local health agencies Provides schools with                             X
collaborate in establishing bacteriological standards for     expertise from relevant
vendor contracts.                                             agencies for purchasing
                                                              food products.
Review microbial testing guidelines of manufacturers.         Ensures adequacy of                                                X
                                                              testing standards.
Perform microbiological testing of food products after        Provides additional                X
delivery to schools.                                          assurance of food quality.
Serve only domestic products in school meal programs.         Eliminates threat of                          X
                                                              pathogens from foreign
                                                              countries.
8. Auditing/monitoring suppliers
Require AMS or other third-party review of production         Helps ensure that suppliers        X          X
facilities used by new and repeat vendors or food service use appropriate food safety
management companies.                                         practices.
Require food service management companies to provide Facilitates trace back of                   X
information on their suppliers by revising federal prototype. contaminated food.
Monitor suppliers throughout contract terms, perform          Helps ensure that suppliers                                        X
monthly product testing, and work with suppliers to correct use appropriate food safety
defects.                                                      and security practices.
Include trace back provisions in supplier contracts and       Facilitates traceback of                      X                    X
require suppliers to notify when it provides products not     contaminated food.
from preapproved sites.
Perform routine monitoring of contract specifications to      Helps ensure that suppliers                                        X
obtain supplier’s compliance with terms of contract.          use appropriate food safety
                                                              and security practices.
Use product specifications and routine monitoring of          Helps ensure that suppliers                   X                    X
suppliers to ensure bacterial control of critical items, such use appropriate food safety
as ground meat and poultry.                                   and security practices.




                                            Page 56                                                     GAO-03-530 School Meals Safety
                                               Appendix IV: Food Safety and Security
                                               Practices for School Meal Programs Used or
                                               Suggested by Government or Private Sector




                                                                                                                       State and
                                                                                                  School      Federal  local       Private
Useful practices and suggestions                                 Benefits                         districts   agencies agencies    sector
Compare school vendor performance information with that Helps ensure that foods                        X
of surrounding school jurisdictions.                             are purchased from
                                                                 reputable suppliers.
Require food brokers and manufacturer representatives to Provides additional food                      X
inspect processors for quality.                                  quality assurance.
Require suppliers to have third-party food safety                Helps ensure that suppliers                                           X
inspections at least once a year.                                use appropriate food safety
                                                                 and security practices.
9. Equipment and facilities
Use coolers that minimize temperature fluctuations, such Facilitates maintaining                       X                               X
as those with plastic strips in doorways.                        proper food storage
                                                                 temperatures.
Install internal doors that have pressurized air curtains and Reduces pest infestation                                                 X
bug lights.
Install computer-controlled disinfectant dispensers on           Ensures proper strength of                                            X
sinks.                                                           disinfectants.
Install hand sanitizer dispensers in lunch room to allow         Encourages proper                     X
quick hand washing for time-constrained students.                personal hygiene.
Use a metal detector to identify metal fragments in food.        Detects potentially                   X
                                                                 dangerous foreign objects
                                                                 in foods.
Use temperature monitors that withstand power outages. Facilitates maintaining                                    X
                                                                 proper food storage
                                                                 temperatures.
10. Recalls
Apply federal recall notification procedures for donated         Faster notification of all            X          X
foods to schools’ commercial food purchases.                     recalls, including
                                                                 commercial recalls.
Add additional state notification points to federal notification Faster notification of recalls                   X          X
system.                                                          to other interested parties.
Implement state fax and e-mail system to immediately send Faster notification of recalls                                     X
recall information to schools.                                   within states.
Register for direct e-mail notification of USDA recalls.         Faster notification to                X
                                                                 schools of recalls.
Monitor recalls on federal agency and other Web sites or Facilitates faster and                                                        X
newsletters.                                                     appropriate response to
                                                                 recalls.
Monitor supplier and distribution information for effective      Facilitates faster and                                                X
communication during recalls.                                    appropriate response to
                                                                 recalls.
Develop state computerized electronic purchasing system Promotes notification to                                  X
linked to local schools that is tied into FSIS recall system. schools of recalls.
Develop memorandum of understanding to allow FSIS to Facilitates faster                                           X
give suppliers’ distribution data on recalled products to        notification of recalls.
states.
11. Health inspections
Conduct health inspections of food service operations two Provides enhanced health                     X                     X
or more times annually.                                          department oversight.



                                               Page 57                                                        GAO-03-530 School Meals Safety
                                              Appendix IV: Food Safety and Security
                                              Practices for School Meal Programs Used or
                                              Suggested by Government or Private Sector




                                                                                                                    State and
                                                                                               School      Federal  local       Private
Useful practices and suggestions                               Benefits                        districts   agencies agencies    sector
Use HACCP format for health inspections of school and          Ensures that critical food           X                     X
central production facilities.                                 safety items are addressed
                                                               during health inspections.
Require schools to immediately notify school district’s food Facilitates faster corrective          X
service directors of health inspection results.                actions.
Require larger schools to consult with health departments Provides health department                                                X
and perform inspections and monitoring of food safety          assistance and quality
management at least annually                                   assurance in schools.
12. Traceback
Require vendors to be able to trace all products back to       Facilitates tracing of                          X
suppliers.                                                     contaminated foods.
Require suppliers to deliver all products to central or county Facilitates tracing of               X
warehouses where practical.                                    contaminated foods.
FOOD SECURITYb
Require background checks of food service workers.             Lessens opportunities for            X                     X         X
                                                               intentional contamination.
Restrict visitor access to kitchens and/or escort visitors in Lessens opportunities for             X          X          X
food preparation areas.                                        intentional contamination.
Secure food preparation and storage areas when not in          Lessens opportunities for            X          X                    X
use.                                                           intentional contamination.
Require locks on all refrigerators, freezers, and/or ice       Lessens opportunities for            X          X                    X
machines.                                                      intentional contamination.
Purchase food from reputable vendors.                          Decreases likelihood of              X          X          X
                                                               receiving adulterated
                                                               products.
Verify the identity of food deliverers.                        Identifies unauthorized              X          X                    X
                                                               personnel.
Disseminate FDA security guidelines to schools.                Promotes food security                                     X
                                                               awareness.
Discuss security procedures with suppliers.                    Promotes food security               X          X
                                                               awareness.
Select suppliers with security statements ensuring a site      Helps ensure that suppliers                     X                    X
security plan, security cameras, perimeter guards, and         use appropriate food
employee identification.                                       security practices.
Inspect food shipments upon arrival.                           Provides opportunity to              X          X
                                                               identify intentional
                                                               contamination.
Require vendors to seal products in tamper evident             Facilitates identification of        X          X
packaging.                                                     contaminated products.
Complete a product evaluation form for unacceptable            Facilitates monitoring of            X          X
products and possibly disqualify suppliers who exceed a        food shipment quality.
prescribed number.
Incorporate security measures in food safety audits.           Focuses attention on food                                            X
                                                               security.
Disseminate USDA’s poster and flyer on food security to        Promotes food security                          X
schools.                                                       awareness.
Disseminate AMS’s paper on security measures, such as Promotes food security                                   X
sealing delivery trucks.                                       awareness.



                                              Page 58                                                      GAO-03-530 School Meals Safety
                                            Appendix IV: Food Safety and Security
                                            Practices for School Meal Programs Used or
                                            Suggested by Government or Private Sector




                                                                                                                   State and
                                                                                             School       Federal  local          Private
 Useful practices and suggestions                             Benefits                       districts    agencies agencies       sector
 Provide ongoing training in food inventory controls,         Promotes food security              X
 handling leftovers, receiving and storing food, and          awareness.
 packaging.
 Install facility access controls, such as coded locks and    Lessens opportunities for            X
 entry intercoms at all food production areas.                intentional contamination.
 Visit suppliers to check for security measures and ensure    Helps ensure that suppliers                                             X
 that all products originate from known suppliers.            use appropriate food
                                                              security practices.
 Require background checks of distributors’ employees.        Lessens opportunities for            X
                                                              intentional contamination.
Source: GAO.
                                            a
                                            Private sector sources we contacted are Chef America, Jack in the Box, Sodexho, and Walt Disney
                                            World.
                                            b
                                             Many food security practices may also be characterized as food safety practices.


                                            The following provides additional information on the supplier-related food
                                            safety practices described in table 7. Three food supplier-related safety
                                            practices could be valuable to school districts that have resources to
                                            implement these practices and have commercial influence over their
                                            suppliers. The first practice—selecting suppliers that employ good food
                                            safety principles and procedures—was used by three entities we
                                            contacted. For instance, Walt Disney World restaurants have a Vendor
                                            Food Safety Program to screen new vendors and monitor existing vendors.
                                            The company stated that it requires food safety evaluations of its potential
                                            vendors, including E. coli O157:H7 testing of vendors’ high-risk foods,
                                            such as beef patties. In addition, the company reviews the Sanitation
                                            Standard Operating Procedures, recall procedures, and HACCP plans of
                                            the operating facilities of prospective suppliers. Moreover, officials of the
                                            Veterans Health Administration told us that they require their vendor to
                                            conduct safety inspections of all warehouses and refrigerated trucks and
                                            to notify all Veterans Health Administration facilities of any food recalls
                                            within 24 hours. In addition, vendors are required to be able to trace all
                                            products back through their suppliers to help track information during
                                            foodborne outbreaks. Finally, according to Jack in the Box, all of its
                                            potential suppliers are required to have HACCP-based food safety
                                            processes.

                                            A second practice—requiring product safety specifications of suppliers—
                                            was used by three entities we contacted. An official at Jack in the Box told
                                            us that the company requires product specifications for different types of
                                            food purchases depending on whether they are raw, ready to eat, or to be
                                            heated prior to serving. The company’s beef safety program requires that



                                            Page 59                                                        GAO-03-530 School Meals Safety
Appendix IV: Food Safety and Security
Practices for School Meal Programs Used or
Suggested by Government or Private Sector




potential suppliers meet certain criteria for microbiological testing of meat
samples for bacteria such as coliform, E. coli O157:H7, Listeria
monocytogenes, Salmonella, and Staphylococcus aureus. In addition,
suppliers are required to report data on the age, bone weight, and number
of foreign objects detected in hamburger patty supplies. Similarly, Walt
Disney World said that it has a zero tolerance policy for E. coli O157:H7
and Salmonella in children’s beef patties. The company also trains smaller
vendors on how to furnish products that meet its requirements and
requires suppliers to inform it when any products from unapproved
production sites are substituted. According to officials at Sodexho, the
company also has product safety specifications and reviews the microbial
guidelines of its suppliers to ensure that products meet specifications.

A third practice—monitoring suppliers’ performance to ensure compliance
with food safety requirements—was used by two entities we contacted.
Jack in the Box’s monitoring program consists of auditing all suppliers
twice a year to examine product safety and quality, employee safety
practices, facilities, and equipment. The audits are designed to evaluate
specific products and the respective processes used for their production.
For example, hamburger patty samples are regularly evaluated for
compliance with physical and chemical specifications. Suppliers must
meet a minimum score to pass an audit. In addition, suppliers are rated
according to their performance in these audits and other product quality
evaluations. Those that receive unsatisfactory ratings must demonstrate
improvement or are no longer allowed to supply the company. Sodexho
officials told us that it also has a supplier-monitoring program. The
company’s Food Safety Team requires safety inspections of all food
vendors by a third-party auditor. Sodexho said that it provides its food
suppliers with a list of approved auditors. As an additional quality and
safety measure, the company said that it monitors the auditors’ efforts by
randomly shadowing them during their vendor audits. The auditors
examine suppliers’ management practices, safety capacity of suppliers’
manufacturing facilities, product compliance with regulatory requirements
and specifications, and effectiveness of suppliers’ quality control measures
in ensuring consistent performance. Sodexho officials told us they also
conduct monthly testing of their products for quality and safety and works
with suppliers to correct defects. The company also assigns staff to
monitor supplier product information during food recalls.




Page 60                                         GAO-03-530 School Meals Safety
             Appendix V: Comments from the Department of Health and Human Services
Appendix V: Comments from the Department
of Health and Human Services




             Page 61                                              GAO-03-530 School Meals Safety
Appendix V: Comments from the Department of Health and Human Services




Page 62                                              GAO-03-530 School Meals Safety
                  Appendix VI: GAO Contacts and Staff
Appendix VI: GAO Contacts and Staff
                  Acknowledgments



Acknowledgments

                  Lawrence J. Dyckman, (202) 512-5138
GAO Contacts      Maria C. Gobin, (202) 512-8418


                  In addition to the individuals named above, Samantha Gross,
Acknowledgments   Charles Hessler, Kurt Kershow, Suen-Yi Meng, and Doug Sloane made
                  significant contributions to this report. Important contributions were also
                  made by Aldo Benejam, Nancy Crothers, Curtis Groves, Judy Pagano, and
                  Kevin Tarmann.




(360246)
                  Page 63                                        GAO-03-530 School Meals Safety
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