School Meal Program: Few Instances of Foodborne Outbreaks	 
Reported, but Opportunities Exist to Enhance Outbreak Data and	 
Food Safety Practices (09-MAY-03, GAO-03-530).			 
                                                                 
More than 28 million children receive meals daily through the	 
federal school meal programs. Providing meals that are safe is	 
especially important because young children have a higher risk of
complications from some foodborne illnesses. GAO examined (1) the
frequency and causes of reported foodborne illness outbreaks	 
associated with the federal school meal programs and (2) the	 
practices that federal, state, and local governments as well as  
other food providers find useful for safeguarding meals.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-530 					        
    ACCNO:   A06832						        
  TITLE:     School Meal Program: Few Instances of Foodborne Outbreaks
Reported, but Opportunities Exist to Enhance Outbreak Data and	 
Food Safety Practices						 
     DATE:   05/09/2003 
  SUBJECT:   Children						 
	     Contaminated foods 				 
	     Food and drug legislation				 
	     Food facilities					 
	     Food inspection					 
	     Food programs for children 			 
	     Food services					 
	     Schools						 
	     Strategic planning 				 
	     National School Breakfast Program			 
	     National School Lunch Program			 

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GAO-03-530

Report to Congressional Requesters

United States General Accounting Office

GAO

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

GAO found that 195, or about 3 percent, of the total of 7,390 foodborne
outbreaks that were reported nationwide, between 1990 and 1999, occurred
in schools. Specific national data on whether these outbreaks were related
to the federal school meal programs do not exist; however, GAO*s survey of
state health officials provided information on 40 large outbreaks
involving these programs. Nearly half of these large outbreaks resulted
from improper food preparation and handling practices in school kitchens.
Most commonly, foods involved in the outbreaks were contaminated with
Norwalk- like viruses, which cause a mild gastrointestinal illness.
However, data limitations make comprehensive assessment of the safety of
school meal

programs difficult. In particular, the reporting mechanism that states use
to voluntarily report outbreaks to the Centers for Disease Control and
Prevention (CDC) does not distinguish between outbreaks in schools
involving the school meal programs and those involving food from other
sources, such as brought from students* homes.

Federal, state, and local governments, as well as other food providers use
a variety of practices to safeguard meals. Some of them may have national
applicability to the federal school meal programs. For example, having key
food service personnel trained and certified in food safety would address
the improper food preparation and handling practices that caused most of
the outbreaks reported in GAO*s survey. Purchasing precooked or irradiated
meat and poultry products could reduce the risk of foodborne illness in
schools. Furthermore, the U. S. Department of Agriculture requires that
some of the commodities it donates to schools be purchased under more
stringent safety standards than the agency*s regulatory requirements for
meat and poultry processors. Currently, these more stringent procurement
requirements are not readily accessible for school districts* use. While
the practicality of applying these food preparation/ handling and
purchasing practices to the nation*s schools has not been assessed,
several food safety experts believe that applying these practices in all
schools would enhance the safety of federal school meals. Some of these
practices would likely lead to increased food costs for schools. More than
28 million children

receive meals daily through the federal school meal programs. Providing
meals that are safe is especially important because

young children have a higher risk of complications from some foodborne
illnesses. GAO examined (1) the frequency and causes of reported foodborne
illness outbreaks associated with the federal school meal programs and (2)
the practices that federal, state, and local governments as well as other
food providers find useful for safeguarding meals.

GAO recommends that the Secretary of Health and Human Services direct the
Director of CDC to modify the Centers* foodborne outbreak reporting
mechanism to add federal school meals as an outbreak category. GAO also
recommends that the

Secretary of Agriculture direct (1) the Administrator of the Agricultural
Marketing Service (AMS) to highlight its more stringent school- related

procurement specifications on the agency*s Web page and (2) the
Administrators of AMS and 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. Highlights of GAO- 03- 530, a 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

Page i GAO- 03- 530 School Meals Safety 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 Contents

Page ii 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 iii 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

This is a work of the U. S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce copyrighted
materials separately from GAO*s product.

Page 1 GAO- 03- 530 School Meals Safety

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.

United States General Accounting Office Washington, DC 20548

Page 2 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 3 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.
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. Results in Brief

Page 4 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 5 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 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. Background

Page 6 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 7 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
associated with the federal school meal programs do not exist. But,
according to our survey of state health officials, about two- thirds of
the foodborne outbreaks involving 50 or more individuals that occurred in
schools from 1990 through 1999 were caused by meals served through the
federal school meal programs. In addition, our survey shows that nearly
half of those outbreaks resulted from improper food preparation and
handling practices within schools, such as improper food storage and poor
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. School Meals Caused the Majority of

Foodborne Outbreaks in Our Survey of School Foodborne Outbreaks

Page 8 GAO- 03- 530 School Meals Safety

Our analysis of CDC data shows that 195 foodborne outbreaks were reported
in schools from 1990 through 1999. To obtain more information on federal
school meal- related outbreaks than is currently available from CDC*s
database, we obtained data from health officials regarding 59 large school
outbreaks that occurred in 25 states. Large outbreaks are those that
involve 50 or more individuals. State health departments are typically
involved in the initial investigation and subsequent reporting to CDC of

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. Our
Survey of State Health

Officials Shows That about Two- Thirds of the Outbreaks We Examined
Involved Foods Served through the School Meal Programs

Page 9 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

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

School meals

40 foodborne outbreaks 5,530 related illnesses

Non- school meals

19 foodborne outbreaks 1,971 related illnesses

Source: GAO and CDC.

GAO survey

59 foodborne outbreaks in schools involving

50 or more individuals 7,501 related illnesses

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

Page 10 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 recently reported on outbreaks that occurred in schools between 1973
and 1997. 10 That report was not specific to federal school meal
outbreaks; moreover, it included colleges and universities. Although CDC*s
findings are generally consistent with those of our survey, CDC reported
that the cause of illness in 60 percent of the outbreaks was unknown. In
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. CDC and FDA Studies Are

Generally Consistent with Our Findings Regarding the Causes of These
Outbreaks

Page 11 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 12 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.

Several important data limitations make routine, accurate, and
comprehensive assessment of food safety in the school meal programs very
difficult. First, as CDC acknowledges, only a small percentage of all
foodborne illness outbreaks are reported by state health officials. These

health officials voluntarily report foodborne outbreaks to CDC using a
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. Available Data Limit

Nationwide Assessment of the Frequency and Causes of Illnesses Associated
with Federal School Meals

Page 13 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 14 GAO- 03- 530 School Meals Safety

Federal, state, and local governments, as well as other food providers,
use a variety of practices to safeguard meals. According to several food
safety experts we consulted, four of these practices could be applied in
all participating schools to enhance the safety of the federal school meal
programs. First, many of the school districts we contacted require
training and certifying of food service workers. Second, several school
districts use risk- based food safety procedures. These two practices
could remedy a 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.

Nine of the 14 local school districts we contacted required training and/
or certification of school food service workers to help ensure that foods
served in the federal school meal programs are safe to eat. Food safety
certification training addresses topics such as proper procedures to
safely 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. Selected
Government

and Private Practices Could Enhance Overall Food Safety in Schools

Training and Certifying School Food Service Workers Enhance Food Safety

Page 15 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 16 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.

Some school food service operations we visited were required by state or
local health authorities to follow food safety procedures based on the
Hazard Analysis and Critical Control Points (HACCP) system. HACCP is a
risk- based system that identifies where contamination is mostly likely to
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. Using Risk- Based Food

Safety Procedures Strengthens Schools* Food Safety Efforts

Page 17 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 HACCPbased

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 online
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 18 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 19 GAO- 03- 530 School Meals Safety

According to some food safety experts, proper precooking or irradiation
would eliminate or reduce potential pathogens from raw meat and poultry
and thus decrease the possibility of foodborne disease outbreaks in school
meals. 22 Some school districts, including six we contacted, use precooked
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 USDAdonated
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 highenergy electrons) to reduce or eliminated microorganisms
that can contaminate food. 23 USDA, School Food Purchase Study: Final
Report, (Washington, D. C.: Oct. 1998). Using Precooked or

Irradiated Meat and Poultry Products Reduces Food Contamination Risks

Page 20 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 21 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 USDAdonated 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 22 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.

As we reported in February 2000, USDA has established policies and
procedures to further ensure the safety of foods purchased for donation to
schools. 27 In particular, AMS*s procurement contracts for school- donated
foods include provisions that specify more stringent testing than is
required by USDA*s FSIS and by FDA. According to AMS officials, AMS
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. USDA Has Established

Contracting Specifications for Enhancing the Safety of Foods It Donates to
Schools

Page 23 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 24 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 riskbased 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.

After the events of September 11, 2001, some school district officials
said that they had reviewed their food security procedures for preventing
deliberate contamination of school meals and while they found them to be
adequate, were reemphasizing them. However, beyond reemphasizing existing
procedures to prevent deliberate contamination, the school 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). Some School Districts Are

Reemphasizing Food Security Practices after the Events of September 11,
2001

Page 25 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
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). Conclusions

Page 26 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
illness associated with the federal school meal programs, we recommend
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

and comment. HHS provided written comments and agreed with our
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
Recommendations for

Executive Action Agency Comments and Our Evaluation

Page 27 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 28 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

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

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. Appendix I:
Scope and Methodology

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

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 Washington 3 *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.

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

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.

Appendix I: Scope and Methodology Page 32 GAO- 03- 530 School Meals Safety

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.

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

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. Appendix II: State Health Departments*

Survey Results

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

Food from the federal school meal programs

Coded as school meal based on telephone

followup Coded as school

meal based on GAO 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 outbreak? n= 59 Responses ranged from 50 to 400,
with a mean of 130 and a median of

100.

3. To what extent, if at all, have each of the following foods been linked
to the cause of the outbreak? n= 59 Laboratory

confirmed Epidemiologically

linked/ not lab- confirmed Suspected but

not lab confirmed or epidemiologically

linked Not

suspected to cause outbreak No answer/

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.

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

Yes (a) No, but there is strong epidemiological support 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

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

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 (a) No, but there is strong epidemiological support for

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 suspecting a specific causative agent, please
indicate which agent is suspected. n= 33 Number of

outbreaks

Salmonella (non- typhoidal) 4

Salmonella Enteritidis 1

Listeria 0

Shigella 2

Clostridium perfringens 4

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

5b. 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= 33 Number of

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 select more than one cause.) n= 40 Number of

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

Appendix II: State Health Departments* Survey Results Page 38 GAO- 03- 530
School Meals Safety

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.

Yes Could obtain information if asked a 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.

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

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,
Appendix III: GAO*s Analysis of CDC Data

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

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

Appendix III: GAO*s Analysis of CDC Data Page 41 GAO- 03- 530 School Meals
Safety

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).

Appendix III: GAO*s Analysis of CDC Data Page 42 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

Year Restaurants Private 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

food preparation Outbreaks Illnesses Illnesses per

outbreak Percent of

outbreaks with 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.

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

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 Columbia 15 2 4 11 0 32

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%

Appendix III: GAO*s Analysis of CDC Data Page 44 GAO- 03- 530 School Meals
Safety

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%

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

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

State Averaged population a Outbreaks Outbreaks per

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

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

State Averaged population a Outbreaks Outbreaks per

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.

Appendix III: GAO*s Analysis of CDC Data Page 47 GAO- 03- 530 School Meals
Safety

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.

Appendix III: GAO*s Analysis of CDC Data Page 48 GAO- 03- 530 School Meals
Safety

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

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

Number of reported outbreaks 0 1,000

2,000 3,000

4,000 Year

1,260 1,393 1,739 1,712

1,381 1,489 1,456 1,937

3,464 Source: GAO analysis of CDC data.

1973- 1975 1976-

1978 1979- 1981 1982-

1984 1985- 1987 1988-

1990 1991- 1993 1994-

1996 1997- 1999

Appendix III: GAO*s Analysis of CDC Data Page 49 GAO- 03- 530 School Meals
Safety

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

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

Number of reported illnesses 0 10,000

20,000 30,000

40,000 50,000

60,000 70,000

80,000 Year

48,537 34,357

43,057 51,159

63,004 50,830

40,215 45,913

70,411 Source: GAO analysis of CDC data.

1973- 1975 1976-

1978 1979- 1981 1982-

1984 1985- 1987 1988-

1990 1991- 1993 1994-

1996 1997- 1999

Appendix III: GAO*s Analysis of CDC Data Page 50 GAO- 03- 530 School Meals
Safety

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

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

Year

Source: GAO analysis of CDC data. Restaurant

Private home School Other

0 500

1,000 1,500

2000 2,500

Number of outbreaks 1973- 1975 1976-

1978 1979- 1981 1982-

1984 1985- 1987 1988-

1990 1991- 1993 1994-

1996 1997- 1999

Appendix III: GAO*s Analysis of CDC Data Page 51 GAO- 03- 530 School Meals
Safety

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

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.

Year 1973-

1975 1976- 1978 1979-

1981 1982- 1984 1985-

1987 1988- 1990 1991-

1993 1994- 1996 1997-

1999

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

0 100

200 300

400 500

600 700

Number of outbreaks

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

Page 52 GAO- 03- 530 School Meals Safety

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). Appendix IV: Food Safety and Security

Practices for School Meal Programs Used or Suggested by Government or
Private Sector

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

Page 53 GAO- 03- 530 School Meals Safety

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

districts Federal agencies

State and local agencies Private

sector FOOD SAFETY 1. Training and certification Require certification of
at least one food service worker in

each school kitchen by use of established certification programs or
through self- or state- developed courses.

Enhances food safety and establishes a standard for food safety education.

X X X X Require or provide ongoing documented training for food service
workers in food safety topics such as controlling food inventory, handling
leftovers, receiving and storing food, using written cleaning and
sanitation procedures, maintaining proper temperatures, and packaging.

Reinforces proper food safety practices and facilitates learning.

X X X X Have local health department monitor certification requirements.
Enforces compliance with

food safety requirements. X X X Use multilingual training courses and post
food safety messages in languages other than English or in graphics that
do not require language instruction.

Promotes training in and understanding of food safety among all food
service workers.

X X Require all food safety trainers to be certified. Establishes a
standard for food safety education. X Train workers on critical control
points of HACCP at each food service workstation. Facilitates food safety

training. X Communicate importance of food safety through video screening
that includes children who got sick from foodborne illness.

Facilitates food safety training and reinforces seriousness of impacts of
foodborne illness.

X

2. Risk- based food safety concepts

Mandate and document self- inspections, such as HACCP checklists provided
by USDA, at each school. Promotes use of risk- based food safety
procedures and

increases monitoring. X X X X

Have USDA develop and disseminate generic HACCP plans for school
districts, such as a template. HACCP plans would be individualized to
school*s food service operations. Promotes use of risk- based food safety
procedures and

establishes a common standard for food safety practices.

X X X Use HACCP- based food safety concepts throughout school food service
operations, such as hygiene, time and temperature controls, prevention of
cross contamination, documentation, training, and self- inspection.

Promotes use of risk- based food safety procedures and establishes common
standard for food safety practices.

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

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

Page 54 GAO- 03- 530 School Meals Safety

Useful practices and suggestions Benefits School districts Federal

agencies State and

local agencies Private

sector

Record and/ or check temperatures of refrigerators, freezers, delivery
trucks, and high- risk foods periodically each day, including maintaining
temperature and daily production records for support and satellite schools
and calibration of thermometers.

Helps ensure proper food preparation, facilitates monitoring, helps detect
any spoilage due to improper food holding, and ensures accuracy of food
temperatures.

X X X Provide templates for different types of food preparation, such as
cooking meat, reheating foods, using prepackaged meals, and preparing
salads.

Promotes use of risk- based food safety procedures and establishes common
standard for food safety practices.

X Adopt food safety measures that exceed the current FDA Food Code, such
as maintaining temperature logs, 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.

Provides additional food safety protection. X X Require school district
authorities to perform food safety

inspections of schools twice a month or when visiting schools.

Increases monitoring of schools* food safety practices.

X X Adopt basic health standards for food service employees that handle
foods, such as preventing employees who are coughing and sneezing from
working.

Minimizes risk of pathogens spread by ill workers.

X X Require suppliers to use HACCP plans or food safety and quality
control programs in their manufacturing practices. Decreases likelihood of

receiving contaminated food. X X

Incorporate critical control points into school lunch program recipes,
which are available on Internet and CD- ROM, and incorporate new food
purchasing guidelines into recipes.

Promotes food safety. X Thoroughly wash fresh produce. Provides additional
food protection. X

3. Food storage, handling, and preparation

Require food service staff to properly use and change gloves or tongs.
Avoids exposure to any

pathogens on hands. X X X X Prohibit food deliveries at loading docks that
are not supervised by authorized staff. Prevents potentially

contaminated/ questionable food products from entering schools.

X X X Develop procedures to address high- risk foods, such as melons,
sprouts, unpasteurized eggs, and salad bar items. Eliminates possible

sources of food contamination and reduces likelihood of contamination.

X X Require proper cooling procedures, such as breaking down batches of
food into shallow serving pans for fast chill, immersing wrapped foods in
ice for fast cooling, or using blast chillers.

Minimizes opportunities for pathogen growth. X X X

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

Page 55 GAO- 03- 530 School Meals Safety

Useful practices and suggestions Benefits School districts Federal

agencies State and

local agencies Private

sector

Spot check deliveries for temperature, labeling, and packaging and record
results. Identifies potentially

contaminated incoming food products. X X

Mark dates on all delivered items and use oldest inventory first.
Facilitates proper inventory

maintenance. X X Require staff to wear hats or hairnets during food
preparation and/ or service. Helps minimize contamination of foods. X X
Use cutting boards that are color- coded by food group and sanitize them
after each use accordingly. Minimizes cross

contamination of foods. X X Properly preserve portions of foods served.
Allows later food safety

testing if problems are suspected.

X X 4. Nonschool meal foods

Adopt policy of discouraging or prohibiting food prepared outside the
school from being served or stored in school facilities.

Minimizes bringing food into schools that is prepared elsewhere.

X X X Require food service staff to be present whenever school kitchen is
used. Allows proper oversight of

school facilities. X X Cater special events from school food service
facility. Minimizes bringing food into schools that is prepared elsewhere.

X 5. Product procurement and menu design Maximize use of precooked meat
and poultry products. Mitigates E. coli O157: H7 and Salmonella exposure,
reduces labor costs, and removes fat from meat and poultry products.

X X X Eliminate high- risk foods, such as alfalfa sprouts, mediumrare
hamburgers, and unpasteurized juices. Reduces potential for

foodborne contamination. X X X

6. Supplier selection

Select suppliers that use HACCP or are more process control oriented (e.
g., HACCP- based) and technologically based.

Provides criteria for selecting better quality suppliers.

X X X Allow flexibility in awarding contracts to the lowest bidder.
Provides flexibility in

selecting suppliers. X X Visit production facilities of all prospective
food suppliers. Helps ensure that suppliers use appropriate food safety
practices.

X Select suppliers according to food safety performance by consulting past
safety records, independent auditing results, supplier facility HACCP
plans, microbial testing results of high risk foods and standard
operating, storage and recall procedures.

Provides criteria for selecting better quality suppliers and food
products.

X X Select processors that are approved by USDA and state agencies when
contracting for additional processing of USDA- donated commodities.

Provides criteria for selecting better quality suppliers.

X

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

Page 56 GAO- 03- 530 School Meals Safety

Useful practices and suggestions Benefits School districts Federal

agencies State and

local agencies Private

sector 7. Product specifications

Award supplier contracts that include food safety requirements, such as
third- party microbiological testing before foods are delivered to schools
and maximum delivery times.

Provides additional assurance of food quality by requiring proper food
holding temperatures and

minimizing potentially contaminated food supplies from entering schools.

X X Apply strictest of USDA, state, or local standards in specifications
required of processing companies. Ensures highest standards

for food safety. X Make food safety- related specifications on AMS Web
page more user friendly. Allows states and districts

to use federal procurement expertise.

X Apply AMS*s procurement specifications for donated commodities that
exceed minimum standards of regulatory agencies to schools* commercial
food purchases.

Enhances food safety of school children. X Use assistance available from
AMS to school districts or

states in developing contract or product specifications. Allows states and
districts to use federal procurement

expertise. X Have state education department and local health agencies

collaborate in establishing bacteriological standards for vendor
contracts.

Provides schools with expertise from relevant agencies for purchasing food
products.

X Review microbial testing guidelines of manufacturers. Ensures adequacy
of testing standards. X Perform microbiological testing of food products
after delivery to schools. Provides additional

assurance of food quality. X Serve only domestic products in school meal
programs. Eliminates threat of pathogens from foreign countries.

X 8. Auditing/ monitoring suppliers

Require AMS or other third- party review of production facilities used by
new and repeat vendors or food service management companies.

Helps ensure that suppliers use appropriate food safety practices.

X X Require food service management companies to provide information on
their suppliers by revising federal prototype. Facilitates trace back of

contaminated food. X Monitor suppliers throughout contract terms, perform
monthly product testing, and work with suppliers to correct defects.

Helps ensure that suppliers use appropriate food safety and security
practices.

X Include trace back provisions in supplier contracts and require
suppliers to notify when it provides products not from preapproved sites.

Facilitates traceback of contaminated food. X X

Perform routine monitoring of contract specifications to obtain supplier*s
compliance with terms of contract. Helps ensure that suppliers

use appropriate food safety and security practices.

X Use product specifications and routine monitoring of suppliers to ensure
bacterial control of critical items, such as ground meat and poultry.

Helps ensure that suppliers use appropriate food safety and security
practices.

X X

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

Page 57 GAO- 03- 530 School Meals Safety

Useful practices and suggestions Benefits School districts Federal

agencies State and

local agencies Private

sector

Compare school vendor performance information with that of surrounding
school jurisdictions. Helps ensure that foods

are purchased from reputable suppliers.

X Require food brokers and manufacturer representatives to inspect
processors for quality. Provides additional food

quality assurance. X Require suppliers to have third- party food safety
inspections at least once a year. Helps ensure that suppliers

use appropriate food safety and security practices.

X

9. Equipment and facilities

Use coolers that minimize temperature fluctuations, such as those with
plastic strips in doorways. Facilitates maintaining

proper food storage temperatures.

X X Install internal doors that have pressurized air curtains and bug
lights. Reduces pest infestation X Install computer- controlled
disinfectant dispensers on sinks. Ensures proper strength of

disinfectants. X Install hand sanitizer dispensers in lunch room to allow
quick hand washing for time- constrained students. Encourages proper

personal hygiene. X Use a metal detector to identify metal fragments in
food. Detects potentially dangerous foreign objects in foods.

X Use temperature monitors that withstand power outages. Facilitates
maintaining proper food storage temperatures.

X 10. Recalls

Apply federal recall notification procedures for donated foods to schools*
commercial food purchases. Faster notification of all

recalls, including commercial recalls.

X X Add additional state notification points to federal notification
system. Faster notification of recalls to other interested parties. X X
Implement state fax and e- mail system to immediately send recall
information to schools. Faster notification of recalls within states. X
Register for direct e- mail notification of USDA recalls. Faster
notification to schools of recalls. X Monitor recalls on federal agency
and other Web sites or newsletters. Facilitates faster and

appropriate response to recalls.

X Monitor supplier and distribution information for effective
communication during recalls. Facilitates faster and

appropriate response to recalls.

X Develop state computerized electronic purchasing system linked to local
schools that is tied into FSIS recall system. Promotes notification to

schools of recalls. X Develop memorandum of understanding to allow FSIS to
give suppliers* distribution data on recalled products to states.

Facilitates faster notification of recalls. X 11. Health inspections

Conduct health inspections of food service operations two or more times
annually. Provides enhanced health department oversight. X X

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

Page 58 GAO- 03- 530 School Meals Safety

Useful practices and suggestions Benefits School districts Federal

agencies State and

local agencies Private

sector

Use HACCP format for health inspections of school and central production
facilities. Ensures that critical food

safety items are addressed during health inspections.

X X Require schools to immediately notify school district*s food service
directors of health inspection results. Facilitates faster corrective

actions. X Require larger schools to consult with health departments and
perform inspections and monitoring of food safety management at least
annually Provides health department

assistance and quality assurance in schools.

X

12. Traceback Require vendors to be able to trace all products back to
suppliers. Facilitates tracing of

contaminated foods. X Require suppliers to deliver all products to central
or county warehouses where practical. Facilitates tracing of

contaminated foods. X FOOD SECURITY b Require background checks of food
service workers. Lessens opportunities for intentional contamination. X X
X Restrict visitor access to kitchens and/ or escort visitors in food
preparation areas. Lessens opportunities for

intentional contamination. X X X Secure food preparation and storage areas
when not in use. Lessens opportunities for

intentional contamination. X X X Require locks on all refrigerators,
freezers, and/ or ice machines. Lessens opportunities for

intentional contamination. X X X Purchase food from reputable vendors.
Decreases likelihood of

receiving adulterated products.

X X X Verify the identity of food deliverers. Identifies unauthorized
personnel. X X X Disseminate FDA security guidelines to schools. Promotes
food security

awareness. X Discuss security procedures with suppliers. Promotes food
security awareness. X X Select suppliers with security statements ensuring
a site security plan, security cameras, perimeter guards, and employee
identification.

Helps ensure that suppliers use appropriate food security practices.

X X Inspect food shipments upon arrival. Provides opportunity to

identify intentional contamination.

X X Require vendors to seal products in tamper evident packaging.
Facilitates identification of

contaminated products. X X Complete a product evaluation form for
unacceptable products and possibly disqualify suppliers who exceed a
prescribed number.

Facilitates monitoring of food shipment quality. X X Incorporate security
measures in food safety audits. Focuses attention on food security. X

Disseminate USDA*s poster and flyer on food security to schools. Promotes
food security

awareness. X Disseminate AMS*s paper on security measures, such as sealing
delivery trucks. Promotes food security awareness. X

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

Page 59 GAO- 03- 530 School Meals Safety

Useful practices and suggestions Benefits School districts Federal

agencies State and

local agencies Private

sector

Provide ongoing training in food inventory controls, handling leftovers,
receiving and storing food, and packaging.

Promotes food security awareness. X Install facility access controls, such
as coded locks and

entry intercoms at all food production areas. Lessens opportunities for
intentional contamination. X Visit suppliers to check for security
measures and ensure

that all products originate from known suppliers. Helps ensure that
suppliers use appropriate food

security practices. X

Require background checks of distributors* employees. Lessens
opportunities for intentional contamination. X 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

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

Page 60 GAO- 03- 530 School Meals Safety

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.

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

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 Acknowledgments

Page 63 GAO- 03- 530 School Meals Safety

Lawrence J. Dyckman, (202) 512- 5138 Maria C. Gobin, (202) 512- 8418 In
addition to the individuals named above, Samantha Gross, 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. Appendix VI: GAO Contacts and Staff

Acknowledgments GAO Contacts Acknowledgments

(360246)

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