FOOD SAFETY TRENDS DATA INSIGHTS AND SOLUTIONS STEPHEN

FOOD SAFETY TRENDS, DATA INSIGHTS, AND SOLUTIONS STEPHEN ENGEL RD&E DIRECTOR April 18, 2018 1

Our Shared Purpose THE WORK WE DO MATTERS Every day Ecolab makes the world cleaner, safer and healthier Protecting people and vital resources 2 © 2018 Ecolab USA Inc. All rights reserved.

Safe Food is Fundamental to Life y y y Food borne illness is a growing public health problem around the globe Diets moving from grains to proteins in emerging markets Population growth plus diet shift means 75 -100% more calories needed to feed the world The many stressors on the food supply can lead to unsafe foods unless robust programs exist Must focus on operational, regulatory and reputational risks Everyone has a role in promoting food safety 3 © 2018 Ecolab USA Inc. All rights reserved.

Ecolab Food Safety & Military History y Developed in 1935 at Ecolab and University of Minnesota y Used to sanitize milk cans and glasses y Military solution for front line threat – disease y Kept Economics Laboratory going 4 © 2018 Ecolab USA Inc. All rights reserved.

Cost of Foodborne Illnesses Direct Costs of an Outbreak • ~$75 K* per establishment in • Legal fees • Medical claims • Lost wages • Sanitizing costs Business Risk Public Health Risk • Potential $millions in lost sales across a chain • Word of mouth and social media • Traditional media coverage • Regulatory action • Estimates: • 48 million cases** of foodborne illness in the US annually • 120, 000 hospitalizations • 3000 deaths 5 Operational Readiness Risk • Impact to mission readiness and security • Immobilized troops *NRA estimate © 2018 Ecolab USA Inc. All rights reserved. **http: //www. cdc. gov/foodborneburden/

6 Discussion Overview y Food safety trends and data y Review of contributing factors § § Norovirus discussion & lessons learned CDC Data Additional risk factors y § Food Code and inspection/audit data y Top issues, relevant examples and impact y Mitigating strategies, risk reduction solutions 6 © 2018 Ecolab USA Inc. All rights reserved.

Food Safety Data y Foodborne illness is a significant public health and operational readiness concern y Food safety includes management of production to consumption, and many steps in between y We need to take action to drive rates down, and to do this best, information is needed to most effectively focus efforts y. A lot of data, but in many different formats, posing challenges for its examination y Having a consistent way to examine the data would be valuable y Review examples of how consistent data examination can drive improvements in food safety practices 7 © 2018 Ecolab USA Inc. All rights reserved.

Foodborne Illness Annual Estimates Canada Ø 4 million cases United States Ø 48 million cases Ø 120, 000 hospitalizations Ø 3000 deaths China - Surveillance EU Ø 45. 5 million cases beginning South Korea Ø 336, 000 cases Africa - Surveillance beginning Australia Ø 4. 1 million cases Ø 86 deaths Global foodborne illness estimate: 600 million cases and 420, 000 deaths 8 © 2018 Ecolab USA Inc. All rights reserved.

US Reported Foodborne Illness 2015: Attributed to Food Commodity Groups Rank Order and Number Of Outbreaks Attributed To Food Groups 40 35 30 25 20 15 10 5 ed s ut s an d se ro u ts e Sp am G try ul O th er N O th er po im al s ns An ac Ac qu at ic st R Ve ge ea er bs H ru C gs ge ta bl es oo t ve Eg ui ts Fr ta b B Se le ro eef ed w cr ed op ve s ge ta bl es G ra Tu in rk s ey an d be an s s ol lu sk ry ai M D rk Po en ck C hi Fi sh 0 Source: https: //www. cdc. gov/foodsafety/pdfs/2015 Food. Borne. Outbreaks_508. pdf 9 © 2018 Ecolab USA Inc. All rights reserved.

Is the food supply less safe than it used to be? y No, but food safety incidents are increasingly more visible y Improved detection & surveillance identifies broad issues § Whole genome sequencing technology identifies and differentiates organisms with more precision y Good news = from a public health standpoint y Emphasizes need for flawless execution of food safety programs across supply chain y Food safety facts can help direct efforts appropriately 10 © 2018 Ecolab USA Inc. All rights reserved.

Where Was Contaminated Food Consumed? When Location Is Known, Reported Data USA, 2015. Percent of total outbreaks Workplace; 1 Farm; 1 Prison/Jail; 1 Camp; 1 Hotel; 1 Nursing home; 1 Fair; 1 Church/Temple; 1 School; 2 Grocery Store; 3 Unknown; 7 Restaurant; 60 Home; 9 Caterer; 14 11 Source: https: //wwwn. cdc. gov/foodborneoutbreaks/ © 2018 Ecolab USA Inc. All rights reserved.

CDC Contributing Factors to Foodborne Illness USA 2015, Reported data Unsafe Source 3. 8% Other; 5. 9% Inadequate Cooking; 9. 2% Improper Holding ; 42. 6% Contaminated Equipment/ Environment , 19. 9% Poor Personal Hygiene; 18. 6% Source: CDC https: //www. cdc. gov/foodsafety/pdfs/2015 Food. Borne. Outbreaks_508. pdf 12 © 2018 Ecolab USA Inc. All rights reserved.

Contributing Factors to Restaurant Outbreaks USA 2006 -07 Inadequate Cleaning Slow Cooling Inadequate Cold Holding Bare Hand Contact Handling by infected person 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 13 Source: Gould, et al. 2013 JFP 76(11): 1824. © 2018 Ecolab USA Inc. All rights reserved.

Infected Food Handler - Norovirus Settings of Norovirus Outbreaks, US, 2009 -2013 Child Care Centers 2% Unknown 8% Correctional facilities 1% (n=3960) Cruises, Vacation 3% Hospitals 4% Schools 6% Military ? Restaurants 10% More to come Long term care facilities 61% Parties & events 5% Source: Vega, et al. 2014 J. Clin Micro 52: 147. 14 © 2018 Ecolab USA Inc. All rights reserved.

Norovirus: Leading Cause of Foodborne Illness Norovirus detection improving 1998 enhanced surveillance # Outbreaks Reported 900 Norovirus is hard to kill and challenging to manage New norovirus methods 800 y Survives on surfaces and utensils for weeks y Can remain infectious in food at freezing temperatures and even in some cooked foods y Can spread rapidly in a large population y Can lead to closures and negative publicity Norovirus 700 600 Salmonella 500 C. perfringens 400 E. coli 300 Campylobacter 200 100 Unknown 19 9 19 4 9 19 5 9 19 6 9 19 7 98 19 9 20 9 0 20 0 0 20 1 0 20 2 0 20 3 0 20 4 0 20 5 0 20 6 0 20 7 08 20 0 20 9 1 20 0 1 20 1 12 20 1 20 3 14 0 Source: https: //www. cdc. gov/foodsafety/pdfs/2015 Food. Borne. Outbreaks_508. pdf …but with the right products and procedures, norovirus can be controlled Norovirus is not well understood A 2014 study of food safety professionals by the Journal of Food Protection found that… y “About one-third of respondents did not identify norovirus as one of the three most common foodborne pathogens” y “. . . respondents demonstrated general knowledge of norovirus illness and transmission but could benefit greatly from education regarding prevention and control of norovirus” © 2018 Ecolab USA Inc. All rights reserved.

Transmission Modes in Norovirus Outbreaks 5 US States, Aug 2012 -July 2015 (n=1981) 80 70 60 50 % 40 30 20 10 0 Person to Person Foodborne Other/Unknown Environmental Source: Shah et al. 2017. MMWR, http: //dx. doi. org/10. 15585/mmwr. mm 6607 a 1 16 © 2018 Ecolab USA Inc. All rights reserved.

Norovirus Summary y Estimated 20 million cases in U. S. each year y Symptoms include nausea, vomiting, diarrhea and stomach cramps y Spreads rapidly in large populations § Affects restaurants, hotels, cruise ships, schools, nursing homes, hospitals, correctional facilities and more § Spreads from person to person, through unwashed hands, via contaminated food or water or contact with contaminated surfaces y Resilient under a wide range of conditions y Can damage the reputation of a business y Can undermine operational readiness 17 © 2018 Ecolab USA Inc. All rights reserved. Photo courtesy: Dr. B. V. V. Prasad, Baylor College of Medicine

LESSONS FROM PAST INDUSTRY OUTBREAKS © 2018 Ecolab USA Inc. All rights reserved.

Airborne Outbreak 1998 Dinner Party Outbreak y 126 people attended a dinner at a large hotel. y During the meal, a guest vomited onto a polished wooden floor. y It was immediately cleaned with a mop and disinfectant. y THE MEAL CONTINUED. y Within 48 hours, 52 people reported norovirus symptoms. Source - Marks. 2000. Epidemiol. Infect. 124: 481 -487 19 © 2018 Ecolab USA Inc. All rights reserved.

Airborne Outbreak: Layout Plan of Restaurant Lesson Learned: Appropriate clean up procedures essential to help prevent spread of contamination. Source - Marks. 2000. Epidemiol. Infect. 124: 481 -487 20 © 2018 Ecolab USA Inc. All rights reserved.

Foodborne Outbreak Sub Sandwiches – Michigan, 2005 y Employee returned to work the day norovirus symptoms ended § Same employee sliced lettuce § Lettuce prep sink also used for handwashing y 170 people ill § 3 different lunch events § Restaurant closed twice for cleaning Lesson Learned: Employees must stay home 3 days after symptoms resolve. Need to use enhanced disinfection procedures. Source: MMWR 55(14): 395 -7 21 © 2018 Ecolab USA Inc. All rights reserved.

Cruise Outbreak 1988 Isolated population increases the risk Attack Rate (%) Lesson Learned: Importance of disinfecting environmental surfaces 40 30 20 10 20 30 40 50 60 70 No. of Users per Toilet Source: The Lancet; Oct. 21, 1989; pp 963 22 © 2018 Ecolab USA Inc. All rights reserved.

ADDITIONAL DATA TO CONSIDER IN FOOD SAFETY © 2018 Ecolab USA Inc. All rights reserved.

US Food Code - Basis for Inspections y. A uniform set of provisions that address the safety & protection of food offered at retail and in food service y. A model to safeguard public health & ensure food is not adulterated y Guidance document from FDA that evaluates: § Foodborne illness risk factors § Operational practices y Adopted ways by local & state health departments in a variety of § Requirements vary among jurisdictions § Frequency of inspections and scoring varies among jurisdictions 24 © 2018 Ecolab USA Inc. All rights reserved.

Health Department Inspections Lack of Standardization… y y 3500+ Health Departments across the U. S. 8+ food codes currently in use, inconsistent inspection criteria 100, 000’s of inspections per year Some post online, some make only paper copies Challenging to Manage Internally… y y Extra work for unit level managers Difficult to hold managers accountable Requires additional labor and expenses Standardization to single food code is very difficult High Risk and Visibility… y y Consumers are seeking out inspection results Social media shares inspection results and word travels fast Some Health Departments now post letter grades on store fronts Foodborne illness outbreaks make headlines and hurt brands © 2018 Ecolab USA Inc. All rights reserved.

Health Inspection Data Significance y Millions of restaurant health department (HD) inspections done annually in US y Opportunity exists to mine data to determine role that inspection results can play in helping to identify risks y Develop insights and focus actions appropriately 26 © 2018 Ecolab USA Inc. All rights reserved.

Connecting the dots to focus efforts CDC Data - Top Risk Factors for FBI 1. Improper Holding Temperatures 2. Contaminated Equipment 3. Poor Personal Hygiene 4. Inadequate Cooking 5. Unapproved Source HD Data - Top reasons restaurants fail inspections 1. Food and non food-contact surfaces cleanable, properly designed, constructed and used 2. Physical facilities installed, maintained and clean 3. Food-contact surfaces: cleaned and sanitized 4. Nonfood-contact surfaces clean 5. Adequate handwashing sinks properly supplied and accessible 27 © 2018 Ecolab USA Inc. All rights reserved.

Relevant Examples in the Military y 2009 Germany Military Base Canteen § Norovirus contaminated salad – poor personal and surface hygiene y 2010 SOF Deployment – Entire Unit § High APCs - poor hygiene, surface sanitation, improper food storage, preparation, and handling y 2012 Michigan Military Lunch Party § Staphylococcal Food Poisoning – poor food handling and preparation y 2016 Deployed French Armed Forces § Norovirus – linked to infected food handler, poor hygiene management Would audits, data insights and action have prevented these outbreaks? 28 © 2018 Ecolab USA Inc. All rights reserved.

Additional Food Safety Challenges OPERATORS WANT TO BE PROACTIVE, BUT HAVE A DIFFICULT TIME CREATING A “FOOD SAFETY CULTURE” PEOPLE • • • Conflicting priorities Inconsistent definition/understanding of food safety Don’t fully understand the risks Difficult to undo past practices / procedures Fast pace, constant introduction of new products & processes PROCESSES • Food code / audit action and compliance • Limited comprehensive food safety metrics • Managers & staff: don’t consistently comply w/ standards, variable quality, high turnover, language barriers, cultural differences COSTS • QA teams don’t control significant $ and rarely / never have power or budget • Minimum wage carryover effect – staffing, training 29 © 2018 Ecolab USA Inc. All rights reserved.

Food Safety Data Recap y The problem of food safety is significant. § In US, 1 in 6 of us suffers from a foodborne illness each year y Norovirus y Clearly is difficult to contain if hygiene practices are poor action is needed to drive rates of illnesses down y To be most impactful, efforts need to be focused where they will have the biggest impact y Leveraging data from the CDC and Inspections can help guide efforts appropriately y Multiple solutions are needed to overcome challenges and reduce foodborne illness 30 © 2018 Ecolab USA Inc. All rights reserved.

MITIGATION STRATEGIES AND SOLUTIONS © 2018 Ecolab USA Inc. All rights reserved.

Food Safety Solutions INTERVENTIONS REQUIRED AT MULTIPLE SITES Food Service Operations Retail Agricultural Production Processing Home 32 © 2018 Ecolab USA Inc. All rights reserved.

Operation Risk Reduction Plan y Review current cleaning and hygiene plan. y Have a hygiene plan in place. § Hands should be washed frequently y Do not permit infected workers to prepare food: § While they have symptoms § For at least 3 days after recovery y Discard food that may have been contaminated by an ill person. y Food Code requires that establishments have written procedures to respond to vomiting and diarrheal events 33 © 2018 Ecolab USA Inc. All rights reserved.

Risk Reduction and Remediation Considerations y Organized procedures based on levels of action: § LEVEL GREEN: Standard procedures – maintaining hygiene when norovirus poses no direct threat § LEVEL YELLOW: YELLOW Risk reduction – a heightened defensive response to an outbreak in your area/industry § LEVEL RED: Remediation – a focused response to an outbreak in your facility, designed to break the chain of infection or illness § INCIDENT CLEAN-UP – How to clean an incident of vomitus or stool contamination 34 © 2018 Ecolab USA Inc. All rights reserved.

Products 35 © 2018 Ecolab USA Inc. All rights reserved.

EFFICIENCY Dilution Control Efficiency Reporting Employee Safety Dishmachine Lease Tools & Equipment Machine Warewashing Manual Exterior leaning Warewashing Drain Treatment Floor Care Pest Elimination Water Filtration Kitchen Equipment Repair Food Contact Sanitation Restroom Sanitation Surface Cleaners Water Treatment Water Softening Food Safety Labeling Food Treatment Air Quality Warewashing Equipment Food Safety Consulting Food Safety Solutions Hand Hygiene Health Dept. Intelligence 36 FOOD SAFETY Grease Management WATER CLEANING Multiple Solutions Needed © 2018 Ecolab USA Inc. All rights reserved.

Comprehensive program to get the best results and most sustainable outcomes TECHNOLOGY SERVICE CORE CAPABILITIES TRAINING INFORMATION 37 © 2018 Ecolab USA Inc. All rights reserved.

Taking It to the Next Level Leveraging Information Complete Inspection Analytics and Management Program INSIGHT ACTION RESULTS 1 2 3 4 Fast & Comprehensive Collection Accurate Translation & Analysis Actionable Alerts & Reporting Proven Results & Improvements © 2018 Ecolab USA Inc. All rights reserved.

Closing Thoughts y Strive to decrease foodborne illness y Focus on sustaining operational readiness y Leverage Industry and Inspection Data § Insight on where to focus training and coaching § Broad service, product and program solutions y Goal: Move from Information to Action! Consider… what can you do to prevent another outbreak? 39 © 2018 Ecolab USA Inc. All rights reserved.

Questions? 40 © 2018 Ecolab USA Inc. All rights reserved.