According to the most recently published data by The U.S. Centers for Disease Control and Prevention (CDC), restaurants continue to be the leading cause of foodborne disease outbreaks in the United States, causing 64 percent or more of outbreaks due to an infectious disease each year from 1998–2017 (CDC 2019). 

According to the CDC, the majority of these foodborne disease outbreaks (as well sporadic cases of illnesses not associated with an outbreak) are due to primarily five major risk factors. These five foodborne illness risk factors are directly related to the processes of food sourcing, receiving, storing, preparation, reheating, holding, and food service within all foodservice establishments including restaurant businesses, and include:

  • Food from unsafe sources (e.g., sourcing and/or receiving unapproved (or continuing to serve recalled) ingredients/products, improper temperature and sanitary transportation, and/or date of expiration/improper proper storage issues))
  • Poor personal hygiene (e.g., employees working when sick with foodborne illness, and lack of barriers to cross contamination of foods by hands)
  • Inadequate cooking (e.g., not cooking foods to the required temperatures that will kill all pathogens)
  • Improper holding/time and temperature (e.g., not holding foods at the proper temperature allowing for growth of bacterial pathogens and/or production of toxins)
  • Contaminated equipment/protection from contamination (e.g., not cleaning and sanitizing food contact surfaces, dishware, and food utensils, and the restaurant environmental surfaces that can lead to transmission of pathogens from high touch surfaces to hands to foods)


Of course, there are other hazards that can occur in foods prepared and served by restaurants including chemical (e.g., allergens, cleaning agents, pesticides, etc.) and physical (e.g., bones, plastic, metal shavings, etc.) that cause a customer’s illness or injury, but the majority of the hazards associated with foodborne diseases caused by restaurants are infectious foodborne pathogens that either enter the restaurant as the source of ingredients/products from its suppliers or by its employees who may work while sick. 

The FDA describes a group of highly infectious foodborne pathogens that cause the majority of foodborne illnesses from restaurants the Big 6 pathogens. These Big 6 pathogens have a low infectious dose, infect most persons, are shed by those infected in their body fluids in high numbers. For example, a food employee infected with a “Big 6” pathogen will typically shed hundreds of thousands of pathogens in their body fluids that can be easily transmitted to surfaces to hands to food even when handwashing and gloves are used (see: King, 2019). Consequently, the numbers of customers infected can be high (an outbreak) and the illnesses experienced by the consumer can be very severe as well.

The “Big 6” include:

  • Norovirus
  • Salmonella Typhi
  • Shiga toxin-producing Escherichia coli
  • Shigella spp.
  • Hepatitis A virus
  • Salmonella (nontyphoidal)


All of these hazards that lead to foodborne illness and injury in restaurants can be controlled by the use of a well-developed Process HACCP plan and a Food Safety Management System (FSMS) executed daily (see these methods in King, 2020).  The FDA analyzed hundreds of restaurants across the United States (representing a significant sample of the proportion of the U.S. population that patronize restaurants), to investigate the relationship between FSMS’s used by restaurants, and the occurrence of the top five risk factors and additional food safety behaviors/practices commonly associated with foodborne disease outbreaks (See: FDA 2018). 

Investigators performed an unannounced audit using the FDA Food Code to inspect 396 full-service restaurants and 425 fast food restaurants in multiple states. The number one factor that correlated to a fewer number of these foodborne illness risk factors in both fast-food and full-service restaurants was the execution of a daily FSMS.

However, when a food safety emergency occurs, the FSMS alone may not prevent the occurrence of a foodborne disease outbreak without additional Emergency Operating Procedures (EOP’s), the training, and tools available to mitigate the increased risk caused by the emergency.  A food safety emergency occurs in a restaurant when there is a major loss of control of a hazard, or a new hazard is introduced into the restaurant environment that can cause a foodborne illness or outbreak. 

The most recognized food safety emergency in a restaurant business (although not the most common) is a food recall, where a normally safe source of food from a supplier is found to be unsafe due to a previously unknown hazard identified after production and distribution to a restaurant. It can become a food safety risk to a restaurant business before the food ingredient/product is recalled if used to prepare and serve food to customers (often causing large multi-state foodborne disease outbreaks) and/or if the ingredient/product is continually sold to customers because the recall was not effectively communicated and executed by the restaurant. 

For example, the recent onions associated foodborne disease outbreak caused by Salmonella, was reported to the public by the Centers for Disease Control and Prevention (CDC) on September 2, 2021 before it was known which supplier(s) distributed the onions,  and then later voluntarily recalled and communicated by the distributors/supplier on October 20 and 22, respectively.  This type of food safety emergency can significantly impact a restaurant’s business financially even if no cases of illness are associated with the restaurant if the restaurant cannot determine the source of their onions (i.e., they would likely make a decision to remove the onions from food prep and service to err on the side of caution).

This is why it is very important to have a risk-based supplier sourcing and management system in place to ensure a safe source of ingredients/products distributed to each restaurant.   

A food ingredient/product recall is not the most common food safety emergency that a restaurant business will experience.  In fact, the topmost common food safety emergency’s that regularly occur in a restaurant business are:

1. Customer claim of foodborne illness or allergic reaction to food (or health department investigation occurs of such) or customer injury due to a foreign body in food,

  • Many customers will claim illness from the last food they ate, but often times the illness is the result of food intolerances or other causes not related to food,
  • Quick action can not only recover a potentially lost customer (where there was only a misperception of illness), but prevent a larger foodborne disease outbreak if an actual multiple customer illness is caught early


2. Employee working sick with a foodborne illness (or health department investigation report of such) is the most difficult food safety emergency to prevent and the most common

  • You can’t tell when an employee is sick. Unless they physically vomit in the restaurant (see below) or they tell you they have the symptoms (vomiting and diarrhea) if signs of illness are not evident (e.g., jaundiced eyes, fever, etc.)
  • Employees can be sick but have no foodborne illness signs or symptoms (up to two weeks after being sick as well)
  • Employees may work while sick anyway and not share they have illness
  • Employees that are excluded from one restaurant may work at another restaurant (i.e., are employed by multiple businesses)
  • Employees (if discovered sick/excluded while on their shift) will have already spread the pathogens on restaurant surfaces
  • Thus a prerequisite EOP must be in place by the restaurant manager performing wellness checks of each employee each shift (the same used during this pandemic to screen and exclude employees properly for symptoms of COVID19) including proper use of a sick log to ensure sick employees don’t return to work until not sick


3. Boil water advisory notice where there is no potable water for use in dish washing, hand washing, and for preparing foods

  • Restaurant businesses notice of a boil water advisory is a common event across the industry, and the resulting loss of sales can be large if the business is not allowed to operate with alternative EOP’s
  • Several states require a restaurant business (e.g., See Georgia) to provide their local health department a copy of their EOP for preapproval of operations before a boil water advisory occurs in order to remain open for business during an advisory notice.


4. Power outages where refrigeration, freezers, and equipment used to keep foods hot is loss

  • A power outage can occur unexpectantly especially during thunderstorms, winter storms, or local construction in the vicinity of the restaurant business
  • There are strict FDA and USDA requirements on how long foods may be held and/or used in restaurants during and after a power outage based on the type of food (e.g., fresh produce, prepared foods, packaged foods, etc.) and how the foods are held or stored


5. Natural disaster (hurricane, tornado, winter storms) that lead to power outages, flooding, or high-risk conditions for cross contamination of foods with pathogens and chemicals

  • After even temporary or low volume flooding of restaurants, there are strict requirements for which foods may be saved after flood waters are remediated
  • Power outages for long periods of time can significantly impact cost if EOP’s are not used to protect the foods


6. Body fluid spill in the restaurant (by customer or employee)

  • A single body fluid event (e.g., vomiting in the kitchen by an employee or in the restroom or dining room by either a customer or employee) can lead to a large foodborne disease outbreak if the proper EOP is not used for cleaning and sanitation of the fluids on surfaces.
  • The FDA requires and most states enforce a requirement for a restaurant business to have a EOP for body fluids clean up (see QSR) as well for this reason


Emergency Operating Procedures (EOP’s) for each of these food safety emergencies and managers and employees trained on how to execute them are critical to a restaurants businesses ability to reduce the risk of a foodborne disease outbreak caused by the food safety emergency. EOP’s need to be available before the events in order to train employees on the procedures but also immediately during the event to ensure each different EOP is executed properly. 

A new mobile app has been created called EmergiProtect that provides these EOP’s based on the FDA Food Code and other recognized credible resources (e.g., the Conference for Food Protection) including proper wellness screening of employees for COVID19 and foodborne illnesses. This mobile app is available to restaurant employees so that each has immediate access (on their smart phone) to ensure accurate execution of the top six food safety EOP’s, and can be used to train all employees prior to these events (as the app is provided as a free download resource from the two major app stores (Apple and Google) sponsored by Purell).

In this new era of the COVID-19 pandemic, the restaurant industry has significantly evolved toward the safety of employees and customers executing improved cleaning and sanitation SOPs, employee wellness screening for COVID19, and a focus on customer safety. These actions the restaurant industry have taken may have affected a reduction of foodborne disease outbreaks across the industry in the United States (See: CDC 2021). The use of FSMS’s to prevent foodborne disease illnesses and the current SOPs to prevent COVID19 should continue. Because food safety emergencies are inherent in the restaurant business, the restaurant operator must also be prepared for these additional public health risk in order to protect their customers and grow their business.

Hal King, Ph.D. is the Managing Partner of Active Food Safety ( ), an advisory services company whose partners developed the free EmergiProtect mobile app for the restaurant industry. Hal can be reached at  

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