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entitled 'School Meal Program: Few Instances of Foodborne Outbreaks 
Reported, but Opportunities Exist to Enhance Outbreak Data and Food 
Safety Practices' which was released on June 05, 2003.

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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 Highlights:

Highlights of GAO-03-530, a report to Congressional Requesters

Why GAO Did This Study:

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.


What GAO Found:

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.

what GAO Recommends:

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.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

School Meals Caused the Majority of Foodborne Outbreaks in Our Survey 
of School Foodborne Outbreaks:

Selected Government and Private Practices Could Enhance Overall Food 
Safety in Schools:

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: State Health Departments' Survey Results:

Appendix III: GAO's Analysis of CDC Data:

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

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

Appendix VI: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Acknowledgments:

Tables:

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

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

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:

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:

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

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

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

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:

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

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

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

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

Abbreviations:

AMS: Agricultural Marketing Service
ASFSA: American School Food Service Association CDCCenters 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:

United States General Accounting Office:

Washington, DC 20548:

May 9, 2003:

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

The Honorable Richard G. Lugar
United States Senate:

More than 28 million children receive meals daily in almost all of the 
nation's public schools, and in many private schools, through the 
federally funded National School Lunch Program and School Breakfast 
Program. The principal goals of these programs--which cost the federal 
government an estimated $8 billion in fiscal year 2002--are to provide 
low cost or free meals to children and to help support the agricultural 
economy. These meals are generally safe, but our analysis of data from 
the Centers for Disease Control and Prevention (CDC) shows that 195 
outbreaks of foodborne illness were reported in schools between 1990 
and 1999. These outbreaks involved about 12,000 individuals.[Footnote 
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.[Footnote 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 
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.[Footnote 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 school meals.[Footnote 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.

Results in Brief:

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 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 
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.

Background:

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.[Footnote 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, 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.[Footnote 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 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.[Footnote 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.

School Meals Caused the Majority of Foodborne Outbreaks in Our Survey 
of School Foodborne Outbreaks:

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.

Our Survey of State Health Officials Shows That about Two-Thirds of the 
Outbreaks We Examined Involved Foods Served through the School Meal 
Programs:

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.[Footnote 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.

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:

[See PDF for image]

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).

[End of figure]

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 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.[Footnote 9] 
Appendix II provides further information about our survey to state 
health department officials.

CDC and FDA Studies Are Generally Consistent with Our Findings 
Regarding the Causes of These Outbreaks:

CDC recently reported on outbreaks that occurred in schools between 
1973 and 1997.[Footnote 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 third most frequently reported causes 
of illness.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 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 compliance), and bare-hand contact with ready-to-eat foods (34 
percent of observations were out of compliance).

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

Available Data Limit Nationwide Assessment of the Frequency and Causes 
of Illnesses Associated with Federal School Meals:

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.

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.[Footnote 15]

Selected Government and Private Practices Could Enhance Overall Food 
Safety in Schools:

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.

Training and Certifying School Food Service Workers Enhance Food 
Safety:

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.[Footnote 16] This means that nearly 
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.[Footnote 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.[Footnote 18]

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.[Footnote 19] In 
addition, 1.5 million food service workers have been certified by 
National Restaurant Association's "ServSafe" food safety training 
program.

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

Using Risk-Based Food Safety Procedures Strengthens Schools' Food 
Safety Efforts:

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

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

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

Using Precooked or Irradiated Meat and Poultry Products Reduces Food 
Contamination Risks:

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.[Footnote 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.[Footnote 23] However, USDA does not have similar 
information on its purchases of poultry products. Nevertheless, during 
fiscal year 2002, AMS purchased 16.4 million pounds of cooked diced 
chicken; 5.5 million pounds of cooked cut-up chicken; and 5.3 million 
pounds of cooked chicken fajita strips, patties, and nuggets for 
donation.

However, USDA officials said that precooking meat and poultry adds to 
the cost of those foods and could reduce the overall amount of USDA-
donated commodities provided to local school districts. For example, 
raw chicken costs USDA about 50 cents per pound, and precooked chicken 
costs USDA about $1.35 per pound. Specifically, USDA officials told us 
that requiring USDA to donate only precooked meats or poultry would 
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.[Footnote 24] FDA and USDA have approved 
irradiation for reducing pathogens in raw meat and poultry 
products,[Footnote 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.[Footnote 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 any irradiated meat and poultry products to the federal 
school meal programs. According to USDA officials, a provision in the 
Farm Security and Rural Investment Act of 2002 directs USDA to allow 
any food safety technology approved by USDA or the Department of Health 
and Human Services, including irradiation, to be used for commodity 
purchase programs, including the federal school meal programs. In 
November 2002, USDA requested public comments on implementing this 
provision. USDA plans to publish its irradiation policy for commodity 
donations later on in 2003. USDA officials noted that costs are 
associated with the irradiation process and that irradiated products 
available in consumer markets cost more than nonirradiated products. 
Therefore, irradiating donated meat and poultry products could add to 
the cost of these foods and, without additional program funding, could 
reduce the overall amount of USDA-donated commodities provided to local 
school districts.

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

Although precooking and irradiation may be viewed as key approaches to 
eliminating foodborne disease, food safety experts and USDA note that 
neither practice provides an absolute guarantee against foodborne 
disease and stress that proper preparation and handling of irradiated 
and precooked meats is still needed. USDA is reviewing the comments it 
received in response to a request for public input on these food safety 
technologies and has not made a final decision on implementation of the 
congressional mandate. Spokespersons for four entities we contacted--
the Conference for Food Protection, the National Food Service 
Management Institute, the National Restaurant Association, and 
Resources for the Future--and others caution that irradiating and 
precooking foods do not protect the food from recontamination through 
mishandling by food service workers during meal preparation.

USDA Has Established Contracting Specifications for Enhancing the 
Safety of Foods It Donates to Schools:

As we reported in February 2000, USDA has established policies and 
procedures to further ensure the safety of foods purchased for donation 
to schools.[Footnote 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,[Footnote 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 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 
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.[Footnote 29] 
Nevertheless, some food advocacy organizations, including the Center 
for Science in the Public Interest and the Consumer Federation of 
America, believe that the absence of minimum national safety 
requirements for the federal school meal programs reduces the assurance 
that all school districts have basic food safety practices in place. 
They believe that creating national requirements for these programs 
would enhance the safety of school meals. Furthermore, the Center for 
Science in the Public Interest and other food safety experts believe 
that four food safety practices in particular--training and 
certification of food service workers, using risk-based food safety 
procedures, using precooked and irradiated meat and poultry products, 
and applying AMS's stricter purchasing specifications--warrant further 
study of their national applicability, including the advantages and 
disadvantages, such as increased costs. These experts believe that such 
a study should address school districts' resource constraints, the 
potential impact on the school meal programs' commodity surplus removal 
mission, and the need to request any specific legislative 
authorization.

Some School Districts Are Reemphasizing Food Security Practices after 
the Events of September 11, 2001:

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 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.[Footnote 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.[Footnote 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.

Conclusions:

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 considered. As we recently reported, school districts in 
selected states experience year-end revenue shortfalls.

Recommendations for Executive Action:

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.

Agency Comments and Our Evaluation:

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 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.

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:

Signed by Lawrence J. Dyckman

[End of section]

Appendix I: Scope and Methodology:

To determine the frequency and causes of foodborne illness associated 
with foods served through the federal school meal programs, we surveyed 
state health officials using a Web-based survey. We focused on state 
health officials because they are typically involved in the initial 
investigation and subsequent reporting to the Centers for Disease 
Control and Prevention (CDC) of foodborne outbreaks and are, therefore, 
able to provide more detailed information. The objectives of our survey 
were to determine 
(1) whether outbreaks listed by CDC were attributed to the federal 
school meal programs and (2) the feasibility of modifying CDC's 
Foodborne Disease Outbreak Surveillance System to gather more specific 
data about outbreaks associated with the school meal programs. 
Regarding the first survey objective, we asked state health officials 
in 32 states about 
97 outbreaks, each of which, according to CDC's surveillance system, 
involved 50 or more individuals and occurred in schools between 1990 
and 1999. Of the 97 outbreaks included in the survey, we excluded some 
from our analysis for the following reasons: states did not respond to 
our inquiries about 3 outbreaks; states responded but lacked sufficient 
information to answer questions about 22 outbreaks; and states reported 
that, according to their records, 13 outbreaks involved fewer than 
50 individuals. The remaining 59 outbreaks in 25 states formed the 
basis of our analysis.[Footnote 32] 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 federal school meal 
programs.[Footnote 33] 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[Footnote 34]--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 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,[Footnote 35] Marler Clark,[Footnote 36] the National Food 
Service Management Institute, the National Restaurant Association, 
Physicians Committee for Responsible Medicine, Resources for the 
Future, and Safe Tables Our Priority.[Footnote 37]

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,[Footnote 38] 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 
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.

[End of section]

Appendix II: State Health Departments' Survey Results:

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

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

[See PDF for image]

[End of table]

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

[See PDF for image]

[End of table]

[End of section]

Appendix III: GAO's Analysis of CDC Data:

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

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

Interestingly, CDC data show that food outbreaks at schools involve 
larger numbers of illnesses than outbreaks that occur in other 
locations. Table 3 shows that over the entire period, the 547 reported 
outbreaks resulting from foods in schools produced 46,461 reported 
illnesses, approximately 10 percent of all illnesses. While each school 
outbreak caused 85 illnesses on average, each outbreak associated with 
foods from restaurants and private homes caused an average of 18 and 13 
illnesses, respectively. Only the category of "other" outbreaks, which 
caused an average of 56 illnesses, approached the average number of 
illnesses associated with school outbreaks, most likely because many of 
the other outbreaks involve institutionalized populations (nursing 
homes, universities, prisons, etc.) as well. Similarly, school 
outbreaks tend to comprise a greater number of large outbreaks when we 
distinguish large outbreaks (involving 50 or more illnesses) from 
smaller ones. As the final column of table 3 shows, 
51 percent of the school outbreaks over the entire period were large, 
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 
patterns probably also involve changes in how each state reports 
foodborne outbreaks.[Footnote 39]

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: 1973-75; Outbreaks: 1,260; Illnesses: 48,537; Hospitalizations: 
1,906; Fatalities: 41.

Year: 1976-78; Outbreaks: 1,393; Illnesses: 34,357; Hospitalizations: 
1,833; Fatalities: 21.

Year: 1979-81; Outbreaks: 1,739; Illnesses: 43,057; Hospitalizations: 
2,177; Fatalities: 66.

Year: 1982-84; Outbreaks: 1,712; Illnesses: 51,159; Hospitalizations: 
2,086; Fatalities: 76.

Year: 1985-87; Outbreaks: 1,381; Illnesses: 63,004; Hospitalizations: 
4,328; Fatalities: 94.

Year: 1988-90; Outbreaks: 1,489; Illnesses: 50,830; Hospitalizations: 
2,349; Fatalities: 57.

Year: 1991-93; Outbreaks: 1,456; Illnesses: 40,215; Hospitalizations: 
1,735; Fatalities: 31.

Year: 1994-96; Outbreaks: 1,937; Illnesses: 45,913; Hospitalizations: 
1,692; Fatalities: 21.

Year: 1997-99; Outbreaks: 3,464; Illnesses: 70,411; Hospitalizations: 
2,013; Fatalities: 47.

Year: Total; Outbreaks: 15,831; Illnesses: 447,483; Hospitalizations: 
20,119; Fatalities: 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.

[End of table]

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

[See PDF for image]

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.

[End of table]

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:
(Continued From Previous Page)

Location of food preparation: Restaurant; Outbreaks: 8,465; Illnesses: 
148,548; Illnesses per outbreak: 17.5; Percent of outbreaks with 50+ 
illnesses: 7.3%.

Location of food preparation: Private home; Outbreaks: 2,404; 
Illnesses: 30,198; Illnesses per outbreak: 12.6; Percent of outbreaks 
with 50+ illnesses: 3.8%.

Location of food preparation: School; Outbreaks: 547; Illnesses: 
46,461; Illnesses per outbreak: 84.9; Percent of outbreaks with 50+ 
illnesses: 50.5%.

Location of food preparation: Other; Outbreaks: 3,704; Illnesses: 
207,191; Illnesses per outbreak: 55.9; Percent of outbreaks with 50+ 
illnesses: 25.0%.

Location of food preparation: Unknown; Outbreaks: 711; Illnesses: 
15,085; Illnesses per outbreak: 21.2; Percent of outbreaks with 50+ 
illnesses: 9.8%.

Location of food preparation: Total; Outbreaks: 15,831; Illnesses: 
447,483; Illnesses per outbreak: 28.3; Percent of outbreaks with 50+ 
illnesses: 12.5%.

[End of table]

Source: GAO analysis of CDC data.

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

State: Alaska; Restaurant: 11; Home: 68; School: 2; Other: 27; Unknown: 
29; Total: 137.

Restaurant: 8.0%; Home: 49.6%; School: 1.5%; Other: 
19.7%; Unknown: 21.2%; Total: 100.0%.

State: Alabama; Restaurant: 90; Home: 15; School: 12; Other: 18; 
Unknown: 1; Total: 136.

Restaurant: 66.2%; Home: 11.0%; School: 8.8%; Other: 
13.2%; Unknown: .7%; Total: 100.0%.

State: Arkansas; Restaurant: 8; Home: 1; School: 3; Other: 13; Unknown: 
0; Total: 25.

Restaurant: 32.0%; Home: 4.0%; School: 12.0%; Other: 
52.0%; Unknown: 0%; Total: 100.0%.

State: Arizona; Restaurant: 37; Home: 21; School: 7; Other: 35; 
Unknown: 3; Total: 103.

Restaurant: 35.9%; Home: 20.4%; School: 6.8%; Other: 
34.0%; Unknown: 2.9%; Total: 100.0%.

State: California; Restaurant: 533; Home: 231; School: 27; Other: 305; 
Unknown: 61; Total: 1,157.

Restaurant: 46.1%; Home: 20.0%; School: 2.3%; Other: 
26.4%; Unknown: 5.3%; Total: 100.0%.

State: Colorado; Restaurant: 59; Home: 21; School: 2; Other: 33; 
Unknown: 4; Total: 119.

Restaurant: 49.6%; Home: 17.6%; School: 1.7%; Other: 
27.7%; Unknown: 3.4%; Total: 100.0%.

State: Connecticut; Restaurant: 102; Home: 41; School: 21; Other: 89; 
Unknown: 8; Total: 261.

Restaurant: 39.1%; Home: 15.7%; School: 8.0%; Other: 
34.1%; Unknown: 3.1%; Total: 100.0%.

State: District of Columbia; Restaurant: 15; Home: 2; School: 4; Other: 
11; Unknown: 0; Total: 32.

Restaurant: 46.9%; Home: 6.3%; School: 12.5%; Other: 
34.4%; Unknown: 0%; Total: 100.0%.

State: Delaware; Restaurant: 8; Home: 3; School: 2; Other: 13; Unknown: 
1; Total: 27.

Restaurant: 29.6%; Home: 11.1%; School: 7.4%; Other: 
48.1%; Unknown: 3.7%; Total: 100.0%.

State: Florida; Restaurant: 675; Home: 122; School: 28; Other: 181; 
Unknown: 33; Total: 1,039.

Restaurant: 65.0%; Home: 11.7%; School: 2.7%; Other: 
17.4%; Unknown: 3.2%; Total: 100.0%.

State: Georgia; Restaurant: 64; Home: 22; School: 24; Other: 45; 
Unknown: 8; Total: 163.

Restaurant: 39.3%; Home: 13.5%; School: 14.7%; Other: 
27.6%; Unknown: 4.9%; Total: 100.0%.

State: Hawaii; Restaurant: 215; Home: 316; School: 6; Other: 89; 
Unknown: 43; Total: 669.

Restaurant: 32.1%; Home: 47.2%; School: .9%; Other: 
13.3%; Unknown: 6.4%; Total: 100.0%.

State: Iowa; Restaurant: 48; Home: 20; School: 3; Other: 26; Unknown: 
2; Total: 99.

Restaurant: 48.5%; Home: 20.2%; School: 3.0%; Other: 
26.3%; Unknown: 2.0%; Total: 100.0%.

State: Idaho; Restaurant: 42; Home: 17; School: 1; Other: 18; Unknown: 
4; Total: 82.

Restaurant: 51.2%; Home: 20.7%; School: 1.2%; Other: 
22.0%; Unknown: 4.9%; Total: 100.0%.

State: Illinois; Restaurant: 292; Home: 61; School: 22; Other: 176; 
Unknown: 12; Total: 563.

Restaurant: 51.9%; Home: 10.8%; School: 3.9%; Other: 
31.3%; Unknown: 2.1%; Total: 100.0%.

State: Indiana; Restaurant: 43; Home: 8; School: 3; Other: 40; Unknown: 
5; Total: 99.

Restaurant: 43.4%; Home: 8.1%; School: 3.0%; Other: 
40.4%; Unknown: 5.1%; Total: 100.0%.

State: Kansas; Restaurant: 30; Home: 6; School: 6; Other: 16; Unknown: 
3; Total: 61.

Restaurant: 49.2%; Home: 9.8%; School: 9.8%; Other: 
26.2%; Unknown: 4.9%; Total: 100.0%.

State: Kentucky; Restaurant: 23; Home: 15; School: 3; Other: 20; 
Unknown: 7; Total: 68.

Restaurant: 33.8%; Home: 22.1%; School: 4.4%; Other: 
29.4%; Unknown: 10.3%; Total: 100.0%.

State: Louisiana; Restaurant: 15; Home: 20; School: 9; Other: 33; 
Unknown: 6; Total: 83.

Restaurant: 18.1%; Home: 24.1%; School: 10.8%; Other: 
39.8%; Unknown: 7.2%; Total: 100.0%.

State: Massachusetts; Restaurant: 133; Home: 28; School: 25; Other: 
118; Unknown: 19; Total: 323.

Restaurant: 41.2%; Home: 8.7%; School: 7.7%; Other: 
36.5%; Unknown: 5.9%; Total: 100.0%.

State: Maryland; Restaurant: 341; Home: 47; School: 7; Other: 105; 
Unknown: 15; Total: 515.

Restaurant: 66.2%; Home: 9.1%; School: 1.4%; Other: 
20.4%; Unknown: 2.9%; Total: 100.0%.

State: Maine; Restaurant: 37; Home: 6; School: 2; Other: 30; Unknown: 
1; Total: 76.

Restaurant: 48.7%; Home: 7.9%; School: 2.6%; Other: 
39.5%; Unknown: 1.3%; Total: 100.0%.

State: Michigan; Restaurant: 236; Home: 21; School: 16; Other: 80; 
Unknown: 100; Total: 453.

Restaurant: 52.1%; Home: 4.6%; School: 3.5%; Other: 
17.7%; Unknown: 22.1%; Total: 100.0%.

State: Minnesota; Restaurant: 204; Home: 53; School: 19; Other: 131; 
Unknown: 11; Total: 418.

Restaurant: 48.8%; Home: 12.7%; School: 4.5%; Other: 
31.3%; Unknown: 2.6%; Total: 100.0%.

State: Missouri; Restaurant: 78; Home: 13; School: 17; Other: 47; 
Unknown: 3; Total: 158.

Restaurant: 49.4%; Home: 8.2%; School: 10.8%; Other: 
29.7%; Unknown: 1.9%; Total: 100.0%.

State: Mississippi; Restaurant: 10; Home: 3; School: 2; Other: 10; 
Unknown: 0; Total: 25.

Restaurant: 40.0%; Home: 12.0%; School: 8.0%; Other: 
40.0%; Unknown: 0%; Total: 100.0%.

State: Montana; Restaurant: 12; Home: 7; School: 2; Other: 7; Unknown: 
13; Total: 41.

Restaurant: 29.3%; Home: 17.1%; School: 4.9%; Other: 
17.1%; Unknown: 31.7%; Total: 100.0%.

State: North Carolina; Restaurant: 44; Home: 5; School: 6; Other: 46; 
Unknown: 4; Total: 105.

Restaurant: 41.9%; Home: 4.8%; School: 5.7%; Other: 
43.8%; Unknown: 3.8%; Total: 100.0%.

State: North Dakota; Restaurant: 14; Home: 12; School: 4; Other: 10; 
Unknown: 4; Total: 44.

Restaurant: 31.8%; Home: 27.3%; School: 9.1%; Other: 
22.7%; Unknown: 9.1%; Total: 100.0%.

State: Nebraska; Restaurant: 26; Home: 12; School: 2; Other: 19; 
Unknown: 1; Total: 60.

Restaurant: 43.3%; Home: 20.0%; School: 3.3%; Other: 
31.7%; Unknown: 1.7%; Total: 100.0%.

State: New Hampshire; Restaurant: 21; Home: 3; School: 10; Other: 22; 
Unknown: 2; Total: 58.

Restaurant: 36.2%; Home: 5.2%; School: 17.2%; Other: 
37.9%; Unknown: 3.4%; Total: 100.0%.

State: New Jersey; Restaurant: 143; Home: 45; School: 13; Other: 103; 
Unknown: 17; Total: 321.

Restaurant: 44.5%; Home: 14.0%; School: 4.0%; Other: 
32.1%; Unknown: 5.3%; Total: 100.0%.

State: New Mexico; Restaurant: 52; Home: 24; School: 8; Other: 23; 
Unknown: 7; Total: 114.

Restaurant: 45.6%; Home: 21.1%; School: 7.0%; Other: 
20.2%; Unknown: 6.1%; Total: 100.0%.

State: Nevada; Restaurant: 13; Home: 4; School: 0; Other: 8; Unknown: 
4; Total: 29.

Restaurant: 44.8%; Home: 13.8%; School: 0%; Other: 
27.6%; Unknown: 13.8%; Total: 100.0%.

State: New York; Restaurant: 2,095; Home: 349; School: 72; Other: 636; 
Unknown: 67; Total: 3,219.

Restaurant: 65.1%; Home: 10.8%; School: 2.2%; Other: 
19.8%; Unknown: 2.1%; Total: 100.0%.

State: Ohio; Restaurant: 463; Home: 103; School: 21; Other: 144; 
Unknown: 20; Total: 751.

Restaurant: 61.7%; Home: 13.7%; School: 2.8%; Other: 
19.2%; Unknown: 2.7%; Total: 100.0%.

State: Oklahoma; Restaurant: 22; Home: 15; School: 5; Other: 19; 
Unknown: 3; Total: 64.

Restaurant: 34.4%; Home: 23.4%; School: 7.8%; Other: 
29.7%; Unknown: 4.7%; Total: 100.0%.

State: Oregon; Restaurant: 69; Home: 44; School: 10; Other: 41; 
Unknown: 24; Total: 188.

Restaurant: 36.7%; Home: 23.4%; School: 5.3%; Other: 
21.8%; Unknown: 12.8%; Total: 100.0%.

State: Pennsylvania; Restaurant: 305; Home: 154; School: 24; Other: 
207; Unknown: 33; Total: 723.

Restaurant: 42.2%; Home: 21.3%; School: 3.3%; Other: 
28.6%; Unknown: 4.6%; Total: 100.0%.

State: Rhode Island; Restaurant: 8; Home: 10; School: 5; Other: 8; 
Unknown: 2; Total: 33.

Restaurant: 24.2%; Home: 30.3%; School: 15.2%; Other: 
24.2%; Unknown: 6.1%; Total: 100.0%.

State: South Carolina; Restaurant: 33; Home: 13; School: 2; Other: 17; 
Unknown: 2; Total: 67.

Restaurant: 49.3%; Home: 19.4%; School: 3.0%; Other: 
25.4%; Unknown: 3.0%; Total: 100.0%.

State: South Dakota; Restaurant: 10; Home: 6; School: 1; Other: 5; 
Unknown: 0; Total: 22.

Restaurant: 45.5%; Home: 27.3%; School: 4.5%; Other: 
22.7%; Unknown: 0%; Total: 100.0%.

State: Tennessee; Restaurant: 45; Home: 18; School: 8; Other: 27; 
Unknown: 2; Total: 100.

Restaurant: 45.0%; Home: 18.0%; School: 8.0%; Other: 
27.0%; Unknown: 2.0%; Total: 100.0%.

State: Texas; Restaurant: 104; Home: 25; School: 15; Other: 53; 
Unknown: 43; Total: 240.

Restaurant: 43.3%; Home: 10.4%; School: 6.3%; Other: 
22.1%; Unknown: 17.9%; Total: 100.0%.

State: Utah; Restaurant: 22; Home: 25; School: 3; Other: 9; Unknown: 0; 
Total: 59.

Restaurant: 37.3%; Home: 42.4%; School: 5.1%; Other: 
15.3%; Unknown: 0%; Total: 100.0%.

State: Virginia; Restaurant: 94; Home: 37; School: 13; Other: 80; 
Unknown: 11; Total: 235.

Restaurant: 40.0%; Home: 15.7%; School: 5.5%; Other: 
34.0%; Unknown: 4.7%; Total: 100.0%.

State: Vermont; Restaurant: 23; Home: 10; School: 11; Other: 34; 
Unknown: 0; Total: 78.

Restaurant: 29.5%; Home: 12.8%; School: 14.1%; Other: 
43.6%; Unknown: 0%; Total: 100.0%.

State: Washington; Restaurant: 1,233; Home: 175; School: 13; Other: 
238; Unknown: 39; Total: 1,698.

Restaurant: 72.6%; Home: 10.3%; School: .8%; Other: 
14.0%; Unknown: 2.3%; Total: 100.0%.

State: Wisconsin; Restaurant: 217; Home: 53; School: 20; Other: 134; 
Unknown: 15; Total: 439.

Restaurant: 49.4%; Home: 12.1%; School: 4.6%; Other: 
30.5%; Unknown: 3.4%; Total: 100.0%.

State: West Virginia; Restaurant: 5; Home: 10; School: 3; Other: 12; 
Unknown: 1; Total: 31.

Restaurant: 16.1%; Home: 32.3%; School: 9.7%; Other: 
38.7%; Unknown: 3.2%; Total: 100.0%.

State: Wyoming; Restaurant: 5; Home: 5; School: 2; Other: 2; Unknown: 
0; Total: 14.

Restaurant: 35.7%; Home: 35.7%; School: 14.3%; Other: 
14.3%; Unknown: 0%; Total: 100.0%.

State: Total; Restaurant: 8,427; Home: 2,345; School: 546; Other: 
3,613; Unknown: 693; Total: 15,624.

Restaurant: 53.9%; Home: 15.0%; School: 3.5%; Other: 
23.1%; Unknown: 4.4%; Total: 100.0%.

Source: GAO analysis of CDC data.

[End of table]

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

State: Alaska; Averaged population[A]: 470,352; Outbreaks: 137; 
Outbreaks per: 100,000 population: 29.1.

State: Alabama; Averaged population[A]: 3,956,482; Outbreaks: 136; 
Outbreaks per: 100,000 population: 3.4.

State: Arkansas; Averaged population[A]: 2,308,471; Outbreaks: 25; 
Outbreaks per: 100,000 population: 1.1.

State: Arizona; Averaged population[A]: 3,322,369; Outbreaks: 103; 
Outbreaks per: 100,000 population: 3.1.

State: California; Averaged population[A]: 26,817,660; Outbreaks: 
1,157; Outbreaks per: 100,000 population: 4.3.

State: Colorado; Averaged population[A]: 3,173,804; Outbreaks: 119; 
Outbreaks per: 100,000 population: 3.8.

State: Connecticut; Averaged population[A]: 3,208,119; Outbreaks: 
261; Outbreaks per: 100,000 population: 8.1.

State: District of Columbia; Averaged population[A]: 643,490; 
Outbreaks: 32; Outbreaks per: 100,000 population: 5.0.

State: Delaware; Averaged population[A]: 648,053; Outbreaks: 27; 
Outbreaks per: 100,000 population: 4.2.

State: Florida; Averaged population[A]: 11,364,512; Outbreaks: 1,039; 
Outbreaks per: 100,000 population: 9.1.

State: Georgia; Averaged population[A]: 6,178,926; Outbreaks: 163; 
Outbreaks per: 100,000 population: 2.6.

State: Hawaii; Averaged population[A]: 1,013,593; Outbreaks: 669; 
Outbreaks per: 100,000 population: 66.0.

State: Iowa; Averaged population[A]: 2,860,564; Outbreaks: 99; 
Outbreaks per: 100,000 population: 3.5.

State: Idaho; Averaged population[A]: 989,413; Outbreaks: 82; 
Outbreaks per: 100,000 population: 8.3.

State: Illinois; Averaged population[A]: 11,596,675; Outbreaks: 563; 
Outbreaks per: 100,000 population: 4.9.

State: Indiana; Averaged population[A]: 5,577,565; Outbreaks: 99; 
Outbreaks per: 100,000 population: 1.8.

State: Kansas; Averaged population[A]: 2,444,686; Outbreaks: 61; 
Outbreaks per: 100,000 population: 2.5.

State: Kentucky; Averaged population[A]: 3,652,138; Outbreaks: 68; 
Outbreaks per: 100,000 population: 1.9.

State: Louisiana; Averaged population[A]: 4,134,872; Outbreaks: 83; 
Outbreaks per: 100,000 population: 2.0.

State: Massachusetts; Averaged population[A]: 5,947,932; Outbreaks: 
323; Outbreaks per: 100,000 population: 5.4.

State: Maryland; Averaged population[A]: 4,554,707; Outbreaks: 515; 
Outbreaks per: 100,000 population: 11.3.

State: Maine; Averaged population[A]: 1,155,308; Outbreaks: 76; 
Outbreaks per: 100,000 population: 6.6.

State: Michigan; Averaged population[A]: 9,344,411; Outbreaks: 453; 
Outbreaks per: 100,000 population: 4.9.

State: Minnesota; Averaged population[A]: 4,294,163; Outbreaks: 418; 
Outbreaks per: 100,000 population: 9.7.

State: Missouri; Averaged population[A]: 5,076,648; Outbreaks: 158; 
Outbreaks per: 100,000 population: 3.1.

State: Mississippi; Averaged population[A]: 2,538,877; Outbreaks: 25; 
Outbreaks per: 100,000 population: 1.0.

State: Montana; Averaged population[A]: 795,590; Outbreaks: 41; 
Outbreaks per: 100,000 population: 5.2.

State: North Carolina; Averaged population[A]: 6,411,032; Outbreaks: 
105; Outbreaks per: 100,000 population: 1.6.

State: North Dakota; Averaged population[A]: 637,877; Outbreaks: 44; 
Outbreaks per: 100,000 population: 6.9.

State: Nebraska; Averaged population[A]: 1,586,202; Outbreaks: 60; 
Outbreaks per: 100,000 population: 3.8.

State: New Hampshire; Averaged population[A]: 1,000,832; Outbreaks: 
58; Outbreaks per: 100,000 population: 5.8.

State: New Jersey; Averaged population[A]: 7,670,118; Outbreaks: 321; 
Outbreaks per: 100,000 population: 4.2.

State: New Mexico; Averaged population[A]: 1,413,516; Outbreaks: 114; 
Outbreaks per: 100,000 population: 8.1.

State: Nevada; Averaged population[A]: 1,122,330; Outbreaks: 29; 
Outbreaks per: 100,000 population: 2.6.

State: New York; Averaged population[A]: 18,191,594; Outbreaks: 
3,219; Outbreaks per: 100,000 population: 17.7.

State: Ohio; Averaged population[A]: 10,913,827; Outbreaks: 751; 
Outbreaks per: 100,000 population: 6.9.

State: Oklahoma; Averaged population[A]: 3,045,248; Outbreaks: 64; 
Outbreaks per: 100,000 population: 2.1.

State: Oregon; Averaged population[A]: 2,747,090; Outbreaks: 188; 
Outbreaks per: 100,000 population: 6.8.

State: Pennsylvania; Averaged population[A]: 11,956,840; Outbreaks: 
723; Outbreaks per: 100,000 population: 6.1.

State: Rhode Island; Averaged population[A]: 987,165; Outbreaks: 33; 
Outbreaks per: 100,000 population: 3.3.

State: South Carolina; Averaged population[A]: 3,302,812; Outbreaks: 
67; Outbreaks per: 100,000 population: 2.0.

State: South Dakota; Averaged population[A]: 701,968; Outbreaks: 22; 
Outbreaks per: 100,000 population: 3.1.

State: Tennessee; Averaged population[A]: 4,770,902; Outbreaks: 100; 
Outbreaks per: 100,000 population: 2.1.

State: Texas; Averaged population[A]: 15,816,544; Outbreaks: 240; 
Outbreaks per: 100,000 population: 1.5.

State: Utah; Averaged population[A]: 1,619,082; Outbreaks: 59; 
Outbreaks per: 100,000 population: 3.6.

State: Virginia; Averaged population[A]: 5,816,035; Outbreaks: 235; 
Outbreaks per: 100,000 population: 4.0.

State: Vermont; Averaged population[A]: 531,943; Outbreaks: 78; 
Outbreaks per: 100,000 population: 14.7.

State: Washington; Averaged population[A]: 4,576,553; Outbreaks: 
1,698; Outbreaks per: 100,000 population: 37.1.

State: Wisconsin; Averaged population[A]: 4,844,758; Outbreaks: 439; 
Outbreaks per: 100,000 population: 9.1.

State: West Virginia; Averaged population[A]: 1,823,926; Outbreaks: 
31; Outbreaks per: 100,000 population: 1.7.

State: Wyoming; Averaged population[A]: 437,336; Outbreaks: 14; 
Outbreaks per: 100,000 population: 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.

[End of table]

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

Year: 1973-75; California: 111; Florida: 47; New York: 155; Ohio: 22; 
Washington: 148; Total: 483.

Year: 1976-78; California: 120; Florida: 25; New York: 380; Ohio: 13; 
Washington: 143; Total: 681.

Year: 1979-81; California: 128; Florida: 52; New York: 530; Ohio: 43; 
Washington: 163; Total: 916.

Year: 1982-84; California: 104; Florida: 49; New York: 658; Ohio: 15; 
Washington: 125; Total: 951.

Year: 1985-87; California: 100; Florida: 27; New York: 410; Ohio: 19; 
Washington: 162; Total: 718.

Year: 1988-90; California: 35; Florida: 45; New York: 335; Ohio: 59; 
Washington: 107; Total: 581.

Year: 1991-93; California: 95; Florida: 38; New York: 297; Ohio: 61; 
Washington: 221; Total: 712.

Year: 1994-96; California: 176; Florida: 140; New York: 250; Ohio: 232; 
Washington: 381; Total: 1179.

Year: 1997-99; California: 288; Florida: 616; New York: 204; Ohio: 287; 
Washington: 248; Total: 1643.

Year: Total; California: 1,157; Florida: 1,039; New York: 3,219; Ohio: 
751; Washington: 1,698; Total: 7,864.

Source: GAO analysis of CDC data.

[End of table]

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

[See PDF for image]

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

[End of figure]

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

[See PDF for image]

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

[End of figure]

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

[See PDF for image]

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

[End of figure]

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

[See PDF for image]

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.

[End of figure]

[End of section]

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

School districts, government agencies, and the private sector use or 
suggest useful food safety and security practices for school meal 
programs. Table 7 presents these practices, which are classified into 
two main categories--food safety and food security. For both main 
categories, the most frequently cited specific categories appears 
first. For example, for food safety the specific category of training 
and certification was most frequently cited and thus appears first. 
Similarly, within each category the most frequently cited practice 
appears first. Table 7 also describes the food safety or security 
benefit of each practice and indicates the type of entity that uses or 
suggests each practice. Some of the practices and suggestions listed in 
the table may not be practical for all school districts, especially 
those that are resource-constrained from either the state or local 
levels.[Footnote 40]

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.

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

Useful practices and suggestions: FOOD SAFETY: 1. Training and 
certification:

Useful practices and suggestions: 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; 
Benefits: Enhances food safety and establishes a standard for food 
safety education; School districts: Yes; Federal agencies: Yes; 
State and local agencies: Yes; Private sector: Yes.

Useful practices and suggestions: 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; Benefits: Reinforces proper food 
safety practices and facilitates learning; School districts: Yes; 
Federal agencies: Yes; State and local agencies: Yes; 
Private sector: Yes.

Useful practices and suggestions: Have local health department monitor 
certification requirements; Benefits: Enforces compliance with food 
safety requirements; School districts: Yes; Federal agencies: Yes; 
State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Use multilingual training courses and 
post food safety messages in languages other than English or in 
graphics that do not require language instruction; Benefits: Promotes 
training in and understanding of food safety among all food service 
workers; School districts: Yes; Federal agencies: Yes; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Require all food safety trainers to 
be certified; Benefits: Establishes a standard for food safety 
education; School districts: No; Federal agencies: No; State 
and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Train workers on critical control 
points of HACCP at each food service workstation; Benefits: 
Facilitates food safety training; School districts: No; Federal 
agencies: No; State and local agencies: No; Private sector: 
Yes.

Useful practices and suggestions: Communicate importance of food safety 
through video screening that includes children who got sick from 
foodborne illness; Benefits: Facilitates food safety training and 
reinforces seriousness of impacts of foodborne illness; School 
districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: 2. Risk-based food safety concepts; 
Benefits: No; School districts: No; Federal agencies: 
No; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Mandate and document self-
inspections, such as HACCP checklists provided by USDA, at each 
school; Benefits: Promotes use of risk-based food safety procedures 
and increases monitoring; School districts: Yes; Federal agencies: 
Yes; State and local agencies: Yes; Private sector: Yes.

Useful practices and suggestions: 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; 
Benefits: Promotes use of risk-based food safety procedures and 
establishes a common standard for food safety practices; School 
districts: Yes; Federal agencies: Yes; State and local agencies: No; 
Private sector: Yes.

Useful practices and suggestions: 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; Benefits: Promotes use 
of risk-based food safety procedures and establishes common standard 
for food safety practices; School districts: Yes; Federal agencies: 
Yes; State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Adopt and use standardized recipes 
with critical control points; Benefits: Promotes use of risk-based 
food safety procedures; School districts: Yes; Federal agencies: Yes; 
State and local agencies: Yes; Private sector: No.

Useful practices and suggestions: 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; Benefits: Helps ensure proper food preparation, 
facilitates monitoring, helps detect any spoilage due to improper food 
holding, and ensures accuracy of food temperatures; School districts: 
Yes; Federal agencies: Yes; State and local agencies: Yes; Private 
sector: No.

Useful practices and suggestions: Provide templates for different types 
of food preparation, such as cooking meat, reheating foods, using 
prepackaged meals, and preparing salads; Benefits: Promotes use of 
risk-based food safety procedures and establishes common standard for 
food safety practices; School districts: No; Federal agencies: 
No; State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: 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; Benefits: Provides additional food safety protection; 
School districts: Yes; Federal agencies: No; State and local 
agencies: Yes; Private sector: No.

Useful practices and suggestions: Require school district authorities 
to perform food safety inspections of schools twice a month or when 
visiting schools; Benefits: Increases monitoring of schools' food 
safety practices; School districts: Yes; Federal agencies: Yes; State 
and local agencies: No; Private sector: No.

Useful practices and suggestions: Adopt basic health standards for food 
service employees that handle foods, such as preventing employees who 
are coughing and sneezing from working; Benefits: Minimizes risk of 
pathogens spread by ill workers; School districts: No; Federal 
agencies: Yes; State and local agencies: Yes; Private sector: No.

Useful practices and suggestions: Require suppliers to use HACCP plans 
or food safety and quality control programs in their manufacturing 
practices; Benefits: Decreases likelihood of receiving contaminated 
food; School districts: No; Federal agencies: Yes; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: 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; 
Benefits: Promotes food safety; School districts: No; Federal 
agencies: Yes; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: Thoroughly wash fresh produce; 
Benefits: Provides additional food protection; School districts: 
No; Federal agencies: No; State and local agencies: No; 
Private sector: Yes.

Useful practices and suggestions: 3. Food storage, handling, and 
preparation; Benefits: No; School districts: No; Federal 
agencies: No; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: Require food service staff to 
properly use and change gloves or tongs; Benefits: Avoids exposure to 
any pathogens on hands; School districts: Yes; Federal agencies: Yes; 
State and local agencies: Yes; Private sector: Yes.

Useful practices and suggestions: Prohibit food deliveries at loading 
docks that are not supervised by authorized staff; Benefits: Prevents 
potentially contaminated/questionable food products from entering 
schools; School districts: Yes; Federal agencies: Yes; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: Develop procedures to address high-
risk foods, such as melons, sprouts, unpasteurized eggs, and salad bar 
items; Benefits: Eliminates possible sources of food contamination and 
reduces likelihood of contamination; School districts: Yes; Federal 
agencies: No; State and local agencies: No; Private sector: 
Yes.

Useful practices and suggestions: 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; Benefits: Minimizes opportunities for pathogen 
growth; School districts: No; Federal agencies: Yes; State and 
local agencies: Yes; Private sector: Yes.

Useful practices and suggestions: Spot check deliveries for 
temperature, labeling, and packaging and record results; Benefits: 
Identifies potentially contaminated incoming food products; School 
districts: No; Federal agencies: Yes; State and local agencies: 
No; Private sector: Yes.

Useful practices and suggestions: Mark dates on all delivered items and 
use oldest inventory first; Benefits: Facilitates proper inventory 
maintenance; School districts: Yes; Federal agencies: Yes; State and 
local agencies: No; Private sector: No.

Useful practices and suggestions: Require staff to wear hats or 
hairnets during food preparation and/or service; Benefits: Helps 
minimize contamination of foods; School districts: Yes; Federal 
agencies: Yes; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: Use cutting boards that are color-
coded by food group and sanitize them after each use accordingly; 
Benefits: Minimizes cross contamination of foods; School districts: 
No; Federal agencies: Yes; State and local agencies: No; 
Private sector: Yes.

Useful practices and suggestions: Properly preserve portions of foods 
served; Benefits: Allows later food safety testing if problems are 
suspected; School districts: Yes; Federal agencies: Yes; State and 
local agencies: No; Private sector: No.

Useful practices and suggestions: 4. Nonschool meal foods; Benefits: 
No; School districts: No; Federal agencies: No; State 
and local agencies: No; Private sector: No.

Useful practices and suggestions: Adopt policy of discouraging or 
prohibiting food prepared outside the school from being served or 
stored in school facilities; Benefits: Minimizes bringing food into 
schools that is prepared elsewhere; School districts: Yes; Federal 
agencies: Yes; State and local agencies: Yes; Private sector: No.

Useful practices and suggestions: Require food service staff to be 
present whenever school kitchen is used; Benefits: Allows proper 
oversight of school facilities; School districts: Yes; Federal 
agencies: Yes; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Cater special events from school food 
service facility; Benefits: Minimizes bringing food into schools that 
is prepared elsewhere; School districts: Yes; Federal agencies: No; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: 5. Product procurement and menu 
design; Benefits: No; School districts: No; Federal agencies: 
No; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Maximize use of precooked meat and 
poultry products; Benefits: Mitigates E. coli O157:H7 and Salmonella 
exposure, reduces labor costs, and removes fat from meat and poultry 
products; School districts: Yes; Federal agencies: No; State and 
local agencies: Yes; Private sector: Yes.

Useful practices and suggestions: Eliminate high-risk foods, such as 
alfalfa sprouts, medium-rare hamburgers, and unpasteurized juices; 
Benefits: Reduces potential for foodborne contamination; School 
districts: No; Federal agencies: Yes; State and local agencies: Yes; 
Private sector: Yes.

Useful practices and suggestions: 6. Supplier selection; Benefits: 
No; School districts: No; Federal agencies: No; State 
and local agencies: No; Private sector: No.

Useful practices and suggestions: Select suppliers that use HACCP or 
are more process control oriented (e.g., HACCP-based) and 
technologically based; Benefits: Provides criteria for selecting 
better quality suppliers; School districts: Yes; Federal agencies: 
Yes; State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Allow flexibility in awarding 
contracts to the lowest bidder; Benefits: Provides flexibility in 
selecting suppliers; School districts: Yes; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: Visit production facilities of all 
prospective food suppliers; Benefits: Helps ensure that suppliers use 
appropriate food safety practices; School districts: Yes; Federal 
agencies: No; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: 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; Benefits: Provides criteria for selecting better quality 
suppliers and food products; School districts: Yes; Federal agencies: 
No; State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Select processors that are approved 
by USDA and state agencies when contracting for additional processing 
of USDA-donated commodities; Benefits: Provides criteria for selecting 
better quality suppliers; School districts: No; Federal agencies: 
No; State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: 7. Product specifications; Benefits: 
No; School districts: No; Federal agencies: No; State 
and local agencies: No; Private sector: No.

Useful practices and suggestions: Award supplier contracts that include 
food safety requirements, such as third-party microbiological testing 
before foods are delivered to schools and maximum delivery times; 
Benefits: Provides additional assurance of food quality by requiring 
proper food holding temperatures and minimizing potentially 
contaminated food supplies from entering schools; School districts: 
Yes; Federal agencies: No; State and local agencies: Yes; Private 
sector: No.

Useful practices and suggestions: Apply strictest of USDA, state, or 
local standards in specifications required of processing companies; 
Benefits: Ensures highest standards for food safety; School districts: 
No; Federal agencies: No; State and local agencies: No; 
Private sector: Yes.

Useful practices and suggestions: Make food safety-related 
specifications on AMS Web page more user friendly; Benefits: Allows 
states and districts to use federal procurement expertise; School 
districts: No; Federal agencies: Yes; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Apply AMS's procurement 
specifications for donated commodities that exceed minimum standards of 
regulatory agencies to schools' commercial food purchases; Benefits: 
Enhances food safety of school children; School districts: No; 
Federal agencies: Yes; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: Use assistance available from AMS to 
school districts or states in developing contract or product 
specifications; Benefits: Allows states and districts to use federal 
procurement expertise; School districts: No; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: Have state education department and 
local health agencies collaborate in establishing bacteriological 
standards for vendor contracts; Benefits: Provides schools with 
expertise from relevant agencies for purchasing food products; School 
districts: No; Federal agencies: Yes; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Review microbial testing guidelines 
of manufacturers; Benefits: Ensures adequacy of testing standards; 
School districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: Perform microbiological testing of 
food products after delivery to schools; Benefits: Provides additional 
assurance of food quality; School districts: Yes; Federal agencies: 
No; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Serve only domestic products in 
school meal programs; Benefits: Eliminates threat of pathogens from 
foreign countries; School districts: No; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: 8. Auditing/monitoring suppliers; 
Benefits: No; School districts: No; Federal agencies: 
No; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Require AMS or other third-party 
review of production facilities used by new and repeat vendors or food 
service management companies; Benefits: Helps ensure that suppliers 
use appropriate food safety practices; School districts: Yes; Federal 
agencies: Yes; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: Require food service management 
companies to provide information on their suppliers by revising federal 
prototype; Benefits: Facilitates trace back of contaminated food; 
School districts: Yes; Federal agencies: No; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Monitor suppliers throughout contract 
terms, perform monthly product testing, and work with suppliers to 
correct defects; Benefits: Helps ensure that suppliers use appropriate 
food safety and security practices; School districts: No; Federal 
agencies: No; State and local agencies: No; Private sector: 
Yes.

Useful practices and suggestions: Include trace back provisions in 
supplier contracts and require suppliers to notify when it provides 
products not from preapproved sites; Benefits: Facilitates traceback 
of contaminated food; School districts: No; Federal agencies: Yes; 
State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Perform routine monitoring of 
contract specifications to obtain supplier's compliance with terms of 
contract; Benefits: Helps ensure that suppliers use appropriate food 
safety and security practices; School districts: No; Federal 
agencies: No; State and local agencies: No; Private sector: 
Yes.

Useful practices and suggestions: Use product specifications and 
routine monitoring of suppliers to ensure bacterial control of critical 
items, such as ground meat and poultry; Benefits: Helps ensure that 
suppliers use appropriate food safety and security practices; School 
districts: No; Federal agencies: Yes; State and local agencies: 
No; Private sector: Yes.

Useful practices and suggestions: Compare school vendor performance 
information with that of surrounding school jurisdictions; Benefits: 
Helps ensure that foods are purchased from reputable suppliers; School 
districts: Yes; Federal agencies: No; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Require food brokers and manufacturer 
representatives to inspect processors for quality; Benefits: Provides 
additional food quality assurance; School districts: Yes; Federal 
agencies: No; State and local agencies: No; Private sector: 
No.

Useful practices and suggestions: Require suppliers to have third-party 
food safety inspections at least once a year; Benefits: Helps ensure 
that suppliers use appropriate food safety and security practices; 
School districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: 9. Equipment and facilities; 
Benefits: No; School districts: No; Federal agencies: 
No; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Use coolers that minimize temperature 
fluctuations, such as those with plastic strips in doorways; Benefits: 
Facilitates maintaining proper food storage temperatures; School 
districts: Yes; Federal agencies: No; State and local agencies: 
No; Private sector: Yes.

Useful practices and suggestions: Install internal doors that have 
pressurized air curtains and bug lights; Benefits: Reduces pest 
infestation; School districts: No; Federal agencies: No; 
State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Install computer-controlled 
disinfectant dispensers on sinks; Benefits: Ensures proper strength of 
disinfectants; School districts: No; Federal agencies: No; 
State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Install hand sanitizer dispensers in 
lunch room to allow quick hand washing for time-constrained students; 
Benefits: Encourages proper personal hygiene; School districts: Yes; 
Federal agencies: No; State and local agencies: No; Private 
sector: No.

Useful practices and suggestions: Use a metal detector to identify 
metal fragments in food; Benefits: Detects potentially dangerous 
foreign objects in foods; School districts: Yes; Federal agencies: 
No; State and local agencies: No; Private sector: No.

Useful practices and suggestions: Use temperature monitors that 
withstand power outages; Benefits: Facilitates maintaining proper food 
storage temperatures; School districts: No; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: 10. Recalls; Benefits: No; 
School districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Apply federal recall notification 
procedures for donated foods to schools' commercial food purchases; 
Benefits: Faster notification of all recalls, including commercial 
recalls; School districts: Yes; Federal agencies: Yes; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Add additional state notification 
points to federal notification system; Benefits: Faster notification 
of recalls to other interested parties; School districts: No; 
Federal agencies: Yes; State and local agencies: Yes; Private sector: 
No.

Useful practices and suggestions: Implement state fax and e-mail system 
to immediately send recall information to schools; Benefits: Faster 
notification of recalls within states; School districts: No; 
Federal agencies: No; State and local agencies: Yes; Private sector: 
No.

Useful practices and suggestions: Register for direct e-mail 
notification of USDA recalls; Benefits: Faster notification to schools 
of recalls; School districts: Yes; Federal agencies: No; State and 
local agencies: No; Private sector: No.

Useful practices and suggestions: Monitor recalls on federal agency and 
other Web sites or newsletters; Benefits: Facilitates faster and 
appropriate response to recalls; School districts: No; Federal 
agencies: No; State and local agencies: No; Private sector: 
Yes.

Useful practices and suggestions: Monitor supplier and distribution 
information for effective communication during recalls; Benefits: 
Facilitates faster and appropriate response to recalls; School 
districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: Develop state computerized electronic 
purchasing system linked to local schools that is tied into FSIS recall 
system; Benefits: Promotes notification to schools of recalls; School 
districts: No; Federal agencies: Yes; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Develop memorandum of understanding 
to allow FSIS to give suppliers' distribution data on recalled products 
to states; Benefits: Facilitates faster notification of recalls; 
School districts: No; Federal agencies: Yes; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: 11. Health inspections; Benefits: 
No; School districts: No; Federal agencies: No; State 
and local agencies: No; Private sector: No.

Useful practices and suggestions: Conduct health inspections of food 
service operations two or more times annually; Benefits: Provides 
enhanced health department oversight; School districts: Yes; Federal 
agencies: No; State and local agencies: Yes; Private sector: 
No.

Useful practices and suggestions: Use HACCP format for health 
inspections of school and central production facilities; Benefits: 
Ensures that critical food safety items are addressed during health 
inspections; School districts: Yes; Federal agencies: No; State and 
local agencies: Yes; Private sector: No.

Useful practices and suggestions: Require schools to immediately notify 
school district's food service directors of health inspection results; 
Benefits: Facilitates faster corrective actions; School districts: 
Yes; Federal agencies: No; State and local agencies: No; Private 
sector: No.

Useful practices and suggestions: Require larger schools to consult 
with health departments and perform inspections and monitoring of food 
safety management at least annually; Benefits: Provides health 
department assistance and quality assurance in schools; School 
districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: 12. Traceback; Benefits: No; 
School districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Require vendors to be able to trace 
all products back to suppliers; Benefits: Facilitates tracing of 
contaminated foods; School districts: No; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: Require suppliers to deliver all 
products to central or county warehouses where practical; Benefits: 
Facilitates tracing of contaminated foods; School districts: Yes; 
Federal agencies: No; State and local agencies: No; Private 
sector: No.

Useful practices and suggestions: FOOD SECURITY[B]; Benefits: No; 
School districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Require background checks of food 
service workers; Benefits: Lessens opportunities for intentional 
contamination; School districts: Yes; Federal agencies: No; State 
and local agencies: Yes; Private sector: Yes.

Useful practices and suggestions: Restrict visitor access to kitchens 
and/or escort visitors in food preparation areas; Benefits: Lessens 
opportunities for intentional contamination; School districts: Yes; 
Federal agencies: Yes; State and local agencies: Yes; Private sector: 
No.

Useful practices and suggestions: Secure food preparation and storage 
areas when not in use; Benefits: Lessens opportunities for intentional 
contamination; School districts: Yes; Federal agencies: Yes; State and 
local agencies: No; Private sector: Yes.

Useful practices and suggestions: Require locks on all refrigerators, 
freezers, and/or ice machines; Benefits: Lessens opportunities for 
intentional contamination; School districts: Yes; Federal agencies: 
Yes; State and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Purchase food from reputable 
vendors; Benefits: Decreases likelihood of receiving adulterated 
products; School districts: Yes; Federal agencies: Yes; State and 
local agencies: Yes; Private sector: No.

Useful practices and suggestions: Verify the identity of food 
deliverers; Benefits: Identifies unauthorized personnel; School 
districts: Yes; Federal agencies: Yes; State and local agencies: No; 
Private sector: Yes.

Useful practices and suggestions: Disseminate FDA security guidelines 
to schools; Benefits: Promotes food security awareness; School 
districts: No; Federal agencies: No; State and local 
agencies: Yes; Private sector: No.

Useful practices and suggestions: Discuss security procedures with 
suppliers; Benefits: Promotes food security awareness; School 
districts: Yes; Federal agencies: Yes; State and local agencies: No; 
Private sector: No.

Useful practices and suggestions: Select suppliers with security 
statements ensuring a site security plan, security cameras, perimeter 
guards, and employee identification; Benefits: Helps ensure that 
suppliers use appropriate food security practices; School districts: 
No; Federal agencies: Yes; State and local agencies: No; 
Private sector: Yes.

Useful practices and suggestions: Inspect food shipments upon arrival; 
Benefits: Provides opportunity to identify intentional contamination; 
School districts: Yes; Federal agencies: Yes; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Require vendors to seal products in 
tamper evident packaging; Benefits: Facilitates identification of 
contaminated products; School districts: Yes; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: Complete a product evaluation form 
for unacceptable products and possibly disqualify suppliers who exceed 
a prescribed number; Benefits: Facilitates monitoring of food shipment 
quality; School districts: Yes; Federal agencies: Yes; State and local 
agencies: No; Private sector: No.

Useful practices and suggestions: Incorporate security measures in food 
safety audits; Benefits: Focuses attention on food security; School 
districts: No; Federal agencies: No; State and local 
agencies: No; Private sector: Yes.

Useful practices and suggestions: Disseminate USDA's poster and flyer 
on food security to schools; Benefits: Promotes food security 
awareness; School districts: No; Federal agencies: Yes; State and 
local agencies: No; Private sector: No.

Useful practices and suggestions: Disseminate AMS's paper on security 
measures, such as sealing delivery trucks; Benefits: Promotes food 
security awareness; School districts: No; Federal agencies: Yes; 
State and local agencies: No; Private sector: No.

Useful practices and suggestions: Provide ongoing training in food 
inventory controls, handling leftovers, receiving and storing food, and 
packaging; Benefits: Promotes food security awareness; School 
districts: Yes; Federal agencies: No; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Install facility access controls, 
such as coded locks and entry intercoms at all food production areas; 
Benefits: Lessens opportunities for intentional contamination; School 
districts: Yes; Federal agencies: No; State and local agencies: 
No; Private sector: No.

Useful practices and suggestions: Visit suppliers to check for security 
measures and ensure that all products originate from known suppliers; 
Benefits: Helps ensure that suppliers use appropriate food security 
practices; School districts: No; Federal agencies: No; State 
and local agencies: No; Private sector: Yes.

Useful practices and suggestions: Require background checks of 
distributors' employees; Benefits: Lessens opportunities for 
intentional contamination; School districts: Yes; Federal agencies: 
No; State and local agencies: No; Private sector: No.

[End of table]

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 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.

[End of section]

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

DEPARTMENT OF HEALTH & HUMAN SERVICES:

Office of Inspector General:

Washington, D.C. 20201:

APR 2 1 2003:

Mr. Lawrence J. Dyckman Director, Natural Resources and Environment:

United States General Accounting Office Washington, D.C. 20548:

Dear Mr. Dyckman:

Enclosed are the department's comments on your draft report entitled, 
"School Meal Programs: Few Instances of Foodborne Outbreaks Reported, 
but Opportunities Exist to Enhance Outbreak Data and Food Safety 
Practices." The comments represent the tentative position of the 
department and are subject to reevaluation when the final version of 
this report is received.

The department provided several technical comments directly to your 
staff.

The department appreciates the opportunity to comment on this draft 
report before its publication.

Sincerely,

Dennis J. Duquette:

Acting Principal Deputy Inspector General:

Signed by Dennis J. Duquette:

Enclosure:

The Office of Inspector General (OIG) is transmitting the department's 
response to this draft report in our capacity as the department's 
designated focal point and coordinator for General Accounting Office 
reports. The OIG has not conducted an independent assessment of these 
comments and therefore expresses no opinion on them.

Comments of the Department of Health and Human Services to the General 
Accounting Office's Draft Report, "School Meal Programs: Few Instances 
of Foodborne Outbreaks Reported, but Opportunities Exist to Enhance 
Outbreak Data and Food Safety Practices" (GAO-03-530):

The Department of Health and Human Services appreciates the opportunity 
to comment on this draft report.

GAO Recommendation:

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 voluntary 
foodborne outbreak reporting mechanism. Specifically, states should be 
prompted to specify whether reported outbreaks involved foods served 
through the federal school meal programs.

Department Response:

National surveillance for foodborne disease outbreaks was established 
by the Centers for Disease Control and Prevention (CDC) in the 1960s to 
collect information that is broadly useful for promoting public health. 
The CDC has worked diligently in recent years to improve surveillance 
for foodborne disease outbreaks, achieving a nearly 3-fold increase in 
the number of outbreaks reported and converting reporting to a rapid 
web-based system. The CDC is committed to maintaining and continually 
improving surveillance for this important health outcome.

The current system for reporting is voluntary and depends on the 
willingness and ability of local health officials to obtain and report 
the requested information. Mindful of the demands that reporting places 
on local officials, CDC has not made a practice of adding questions 
that pertain only to specific settings (e.g., schools, prisons, 
restaurants, private homes) or commodities (e.g., ground beef, romaine 
lettuce, egg products).

However, the current GAO draft report indicates that many state health 
officials are willing to collect and report additional information on 
the source of items implicated in school-associated outbreaks. The CDC 
is amenable to changing current data screens to capture this 
information. To this end, CDC has already taken the following steps:

1) Requested from U.S. Department of Agriculture a definition for 
"federal school meal" items so that state and local health officials 
can properly categorize implicated food items:

2) Drafted questions for capturing this information:

3) Verified the feasibility of adding these questions to the 
appropriate fields of the Electronic Foodborne Outbreaks Reporting 
System.

Before implementation, additions to the data collection form will 
require the approval of the Office of Management and Budget.

[End of section]

Appendix VI: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

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

Acknowledgments:

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.

FOOTNOTES

[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.

[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).

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

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

[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).

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

[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.

[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.

[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.

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

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

[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.

[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.

[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.

[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.

[22] Irradiation involves exposing food briefly to radiant energy (such 
as gamma rays or high-energy electrons) to reduce or eliminated 
microorganisms that can contaminate food.

[23] USDA, School Food Purchase Study: Final Report, (Washington, D.C.: 
Oct. 1998).

[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).

[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.

[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). 

[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).

[32] 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. 

[33] 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.

[34] We also contacted school districts in Florida and North Carolina 
to discuss food safety practices. 

[35] Kids First is a public/private partnership to improve health, 
nutrition, and education in Rhode Island school systems.

[36] Marler Clark is a law firm with extensive experience in 
representing victims of foodborne illness.

[37] 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.

[38] Sodexho, a food service management company, provides food and 
facilities management services to over 400 school districts.

[39] 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).

[40] 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). 

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