Food Protection Trends - May/June 2019 - 219

ards because of limited physical facilities and equipment (5).
The lack of proper storage and preparation space, inadequate
refrigeration and hot holding units, inadequate hand washing
facilities, and absence of a supply of hot and cold potable
water are some of the factors often present in temporary food
establishment operations that may contribute to cross-contamination, inadequate holding temperatures and contamination of food by infected food handlers. Many large events
use volunteers who may have little food handling experience
or have not received any food safety training because of time
limitations. Although studies have been published about the
rates of safety violations for other types of retail eating establishments, little literature exists on the food safety violations
that occur most frequently in temporary food establishments.
The Food and Drug Administration (FDA) publishes a
model food code quadrennially to provide state and local
health authorities charged with regulation of food retail
facilities with the best available science (9). To inform
resource allocation, intervention development and policy
evaluation, the FDA conducted retail food risk factor studies
in 1998, 2003 and 2008 to measure compliance with food
safety behaviors and practices outlined in the food code in
institutional foodservice, restaurants, and retail food stores
(8); temporary food establishments were not included in any
of the studies. Although improvements occurred over the
10-year period, the FDA reported that improper holding/
time and temperature, poor personal hygiene, contaminated
equipment and inadequate protection from contamination
were three areas still in need of significant improvement (8).
A 2014 California EHS-Net study identified risk factors
specific to mobile food trucks in six counties in California.
Nearly 95% of the 95 food trucks visited had at least one
critical risk factor. The most frequently observed risk factor
was improper or lack of handwashing (n = 84), followed
by inadequate or lack of sanitation solution for sanitizing
surfaces (n = 65). Other risk factors observed included
cross-contamination with ready-to-eat foods (n = 57),
refrigeration temperatures above 45°F (n = 42), internal food
temperatures above 41°F (n = 34), and refrigeration units
that were not operating (n = 23) (3).
Numerous outbreaks have been associated with temporary
food establishment environments that are in close proximity
to petting zoos, such as state fairs, including outbreaks
caused by Salmonella, Cryptosporidium, and E. coli O157
(2). It was confirmed that 27 individuals became ill with E.
coli O157:H7 infection after visiting the petting zoo at the
2011 North Carolina state fair (4). This was not the first
outbreak of E. coli O157:H7 at the state fair, as three people
had become ill from food purchased from a food stand in
2006, and 108 petting zoo attendees had become ill in 2004
(4). The proximity of food vendors to sites that have a high
likelihood of harboring potentially harmful bacteria also
contributes to the high risk for these types of temporary
eating establishments. Investigating such outbreaks is difficult

because of the transient nature of the events associated with
the temporary food establishments, and attendees have often
sampled many different foods and beverages.
The purpose of this study was to replicate the methodology
used in the FDA retail food risk factor study, with a focus on
temporary food establishments in North Carolina.
MATERIALS AND METHODS
Using the food safety retail risk factor codes established
by the FDA in their studies, North Carolina public health
officials collected risk factor data during non-regulatory
visits at temporary food establishments in North Carolina.
In October 2014, three data collectors observed and documented, at 59 temporary eating establishments, the establishment conditions and employee food handling and hygiene
behaviors for 42 operational compliance elements associated
with foodborne illness. The 42 elements were divided into
categories with respect to risk factors, including, (1) proper
food temperature (cooking and holding), (2) cross-contamination, (3) hygienic practices, and (4) other topics (such as
obtaining food from an approved source or chemical contamination) (Table 1). Hygienic practices included instances of
handwashing, avoidance of bare hand contact, and employee
health. Some compliance items did not pertain to all establishments; for example, some compliance requirements relate
to handling shellfish, so if the establishment did not handle
shellfish, it was not rated on that item. The goal of establishing categories was to detect patterns in rates of compliance
related to the factors that commonly contribute to foodborne
illness, because such patterns could help to inform decisions
on risk management activities. Each observed factor was recorded by the data collector as in compliance, out of compliance, not observed, or not applicable.
A total of 59 establishments were randomly selected out
of 147 permitted establishments at one multi-day event in
North Carolina, using the FDA standardized data collection
instrument. Sample size was determined on the basis of FDA
guidelines (7). Because the county health department issues
permits for temporary food establishments, their staff has
right of entry for any permitted facility to routinely make
visits to check food safety compliance and take action when
necessary. In this case of non-regulatory visits, the data
collectors introduced themselves and asked to be allowed
to conduct the visit; there were no refusals. Data collectors
then progressed through the data collection instrument and
marked the observed factors as appropriate.
Descriptive statistics were generated for each eating
establishment to determine the extent of non-compliance
within establishments. The mean and standard deviation
for the observed factors and factors out of compliance were
calculated for the 59 eating establishments. The results were
further analyzed by calculating the distributions of noncompliance by the following categories: cooking/holding
temperature, cross-contamination, hygiene, and other

May/June Food Protection Trends

219

Food Protection Trends - May/June 2019

Table of Contents for the Digital Edition of Food Protection Trends - May/June 2019