Food Protection Trends - November/December 2022 - 440

price meal benefits, human resources, and facility planning),
and communications and marketing (35).
The impacts of foodborne illnesses are significant, and
surveillance reports have highlighted the significant health
burden on children. According to the Centers for Disease
Control and Prevention (CDC) Foodborne Disease
Outbreak Surveillance System, between 2000 and 2010
foodborne outbreaks in schools accounted for 3.8% (n =
464) of all outbreaks and 8.2% (n = 20,667) of all illnesses
reported (38). Of the 464 outbreaks reported, 49.2%
involved food handling by a school foodservice worker
(38). In 2005, within the Chicago area school districts four
laboratory-confirmed outbreaks occurred. In two outbreaks,
the same school was affected by improper temperature
controls, which allowed fruit juice and pineapple fruit cups
served at lunch to become contaminated with high levels
of yeast, and 46 individuals became ill (39). A foodborne
outbreak of norovirus infection in August 2005 was linked
to at a welcome-back breakfast at another school where
30 students contracted the virus (15), and an outbreak
of Salmonella Enteritidis infection that was laboratory
confirmed affected five students in one school (15).
CDC (6) data indicate that between 2009 and 2018 114
outbreaks of foodborne illness occurred in elementary and
high schools and in colleges and universities, affecting 5,799
students and resulting in 246 hospitalizations. However,
these numbers could be an undercount. Painter et al. (23)
found that many small foodborne illness outbreaks are not
detected or investigated. In 2009, a confirmed outbreak of
norovirus infection was associated with contaminated ice
and lemonade in an Illinois school (12). Venuto and Garcia
(38) found that over 56% (n = 4,285) of all foodborne
illnesses were associated with norovirus and foodservice
worker practices. A major foodborne illness outbreak in 2012
was caused by Salmonella Enteritidis and affected students
at six schools that utilized the same foodservice company
(16). One student was hospitalized, four others sought care
at an emergency room, and eight others visited a health
care provider. Cremon et al. (9) found that children with
Salmonella-induced gastroenteritis were more likely than
adults to develop long-term health consequences such as
irritable bowel syndrome.
Foodborne illnesses in children are associated with several
factors. Compared with adults, children are more vulnerable
foodborne illness partly because their immune systems are
not fully developed, they have a lower body mass, and they
produce less stomach acid (9). Children also have no control
over the food handling practices used to produce school
meals (6).
Research has also identified major problems with current
school food service systems, such as inadequate time to
prepare food and perform proper food safety practices (32),
poor workforce retention, lack of equipment for scratch
cooking (33), and lack of culinary skills for serving palatable
440 Food Protection Trends November/December
foods that meet nutrition guidelines (25). These issues are
reflected in low levels of student acceptance of served foods
(40). Flure et al. (11) identified school foodservice employee
professional development as critical to school meal program
success. Previous research has indicated an urgent need for
training on school food hygiene and safety practices (4) and
culinary skills (31). In a systematic review of foodservice
training modalities, Reynolds and Dolasinski (27) found that
training consisting of lectures with basic visual aids is the
industry norm and noted a lack of novel approaches. Training
methods that take these factors into consideration could
increase employee confidence, motivation, and the likelihood
of putting knowledge and skills into practice (31).
However, tremendous barriers exist for conducting
training for school foodservice employees, including lack
of physical space. Lee et al. (19) found that attendance
barriers such as timing and limited funds for travel and pay
are perpetual concerns. Tabak and Moreland-Russell (33)
recognized that the labor shortages and the burdens of job
duties added to the lack of time for training. According to
the CDC (5), the three most common food safety errors
contributing to unsafe food and foodborne illness are poor
food handling practices, poor personal hygiene, and crosscontamination.
In
a recent evaluation of food safety knowledge and
microbial status of food-contact surfaces in schools,
significantly higher microbial counts on food-contact surfaces
were found among kitchens in which the level of food safety
knowledge among workers was low (14). Jones et al. (17)
conducted a needs assessment of statewide training in
California, and over half of foodservice directors identified
food safety training as a critical need.
Lee and Liu (18) conducted a statewide review of school
foodservice health inspection reports in Missouri to identify
areas for improvement. The top three critical violations were
food temperature control for potentially hazardous foods,
improper equipment usage, and misuse of poisonous and
toxic materials. The top three noncritical violations were
improper equipment usage, inadequate physical facilities,
and inadequate equipment for holding food at a given
temperature.
Although the concept of identifying food safety violations
in school foodservice is not new, little research has been
conducted on school food safety violations over a period of
time to identify reoccurring food safety violations and trends.
After trends are identified, targeted training interventions can
be developed to mitigate foodborne illness outbreaks. The
aim of the present study was to analyze food safety violations
trends between 2010 and 2019 in a large urban school system
to explore research and educational opportunities. The three
research objectives regarding school foodservice operations
were (i) determine the percentages of food inspections in
which the schools pass or fail; (ii) determine the rates of the
most and least common food safety violations by category
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