Norovirus: Risk Factors Influencing Food Safety Training Among CNAs in Georgia District 3-1’s Long Term Care Facilities
Sharia Hudson
Environmental Compliance Specialist V, Cobb & Douglas Public Health, Georgia
Abstract
Norovirus is a highly infectious pathogen that is responsible for approximately 60% of foodborne illness outbreaks and lasts approximately one to three days with an incubation period ranging from 24 to 48 hours. Individuals who contract Norovirus typically experience symptoms ranging from nausea and abdominal cramps to projectile vomiting and diarrhea. In addition, Norovirus is easily transmissible in closed quarters such as hospitals, cruise ships, schools, and long-term care facilities (LTCFs). Norovirus can also be transmitted easily from hands to food through bare hand contact with ready-to-eat food or via sick and/or infected employees working with food while ill. Therefore, individuals who consumed contaminated food or beverages, risk being infected with Norovirus. Outbreaks of Norovirus in LTCFs can impact both residents and nursing staff such as nursing assistants. Certified nursing assistants (CNAs) play a vital role in the care of residents within LTCFs. They are responsible for assisting the residents in their daily activities such as bathing, cleaning, feeding and any other tasks. Although CNAs receive on-the-job training, the level of training regarding food safety practices is not known. The methodology utilized for this research project consisted of collecting data from nursing assistants through electronic surveys using Survey Monkey. According to the survey, 33% of CNAs received oral food safety training while employed at LTCFs, 79% never received training regarding the five risk factors that contribute to foodborne illness, and 64% stated no food safety certification or training was required.
Key words: Norovirus, Foodborne Illness, Certified Nursing Assistant, Risk Factors, Food Safety
Norovirus: Risk Factors Influencing Food Safety Training Among CNAs in Georgia District 3-1’s Long Term Care Facilities
Background
According to the Centers for Disease Control and Prevention, an estimated 48 million people develop a foodborne illness each year in the United States. Among the approximately 48 million illnesses, Norovirus is the leading pathogen that “contributes to domestically acquired foodborne illnesses,” resulting in 5,461,731 infections in 2018 (CDC, 2018). Norovirus is capable of withstanding temperatures as high as 145°F; therefore, it may remain present in food even after the cooking process (CDC, 2013). Eight foodborne illness outbreaks were reported in Georgia in 2018 according to the National Environmental Assessment Reporting System (NEARS) with Norovirus contributing to 38% of the illnesses (CDC, 2018).
Locally, there were 54 long-term care facilities (LTCF) located in Cobb County and seven long term care facilities in Douglas County in 2020 in which District 3-1 is located (DHD, 2021). From 2016 to 2018, District 3-1 LTCFs experienced a total of 11 norovirus outbreaks among their LTCFs which resulted in seven laboratory confirmed positive cases. Moreover, in 2016, one LTCF experienced two separate outbreaks within the same year (D. Crosby, personal communications, January 13, 2021).
There are five risk factors that contribute to foodborne illness including food from unsafe sources, inadequate cooking, improper holding temperatures, contaminated equipment, and poor personal hygiene (FDA, 2018). During routine inspections conducted from 2016 to 2018, some LTCFs were cited for three common risk factors associated with foodborne illness. The facilities were observed to be out of compliance regarding poor personal hygiene, improper holding temperatures, and/or contaminated equipment (DHD, 2021).
Norovirus, a highly infectious causative agent with a low infectious dose, may remain viable on objects or surfaces for days while spreading rapidly via person-to-person interactions and affecting institutional settings such as prisons, hospitals, and LTCFs. LTCFs are classified as assisted living facilities, skilled nursing facilities, and nursing homes where services for both medical and personal care are provided for individuals who may no longer be able to care for themselves independently (CDC, 2018). Therefore, certified nursing assistants (CNAs) play a vital role in the care of residents within LTCFs. CNAs are responsible for assisting the residents in their daily activities such as bathing, cleaning, feeding and any other tasks (Office of Inspector General, 2002).
There are no known food safety training requirements for certified nursing assistants in Georgia for controlling risk factors to mitigate Foodborne Illness Outbreaks, such as Norovirus, among highly susceptible populations in Long-Term Care Facilities (GAMMIS, 2012). Prior to providing services in LTCFs, CNAs must be trained and certified in a State nursing assistant program. Based on the Federal Regulations under the Office of Inspector General, CNAs were required to complete at least 75 hours of training in a classroom setting and in a practical and/or clinical setting prior to certification (Office of Inspector General, 2002). However, in the State of Georgia, CNAs were required to acquire a minimum of 85 hours of classroom and laboratory experience along with at least 24 hours of clinical training in a nursing home setting (GAMMIS, 2012). During their training, CNAs were educated in the following areas: basic nursing skills personal; care skills which includes a section focusing on proper feeding techniques and assisting with hydration and eating, mental health and social service skills, caring for cognitively impaired residents, basic restorative skills, and residents’ rights. Certified nursing assistants are required to pass the written/oral and skills state competency examination within a year of completing the training program. However, food safety training, such as food preparation and food handling, is not a requirement during the certification of nursing assistants (GAMMIS, 2012)
Problem Statement
Although CNAs receive some on-the-job training, their level of training regarding food safety practices or concerning the five major risk factors that contribute to foodborne illnesses is not known
Research Questions
1. How are certified nursing assistants trained regarding food safety practices?
2. What subjects or topics related to food safety are covered during the training of certified nursing assistants?
3. What kind of food safety training is required for certified nursing assistants?
4. How often is the curriculum updated to reflect current standards?
Methodology
The methodology utilized for this research project consisted of collecting data from certified nursing assistants regarding their food safety training via electronic surveys using Survey Monkey. In addition, an interview was conducted via email with the Georgia Medical Foundation regarding CNA training requirements.
Furthermore, the Digital Health Department (DHD) database was utilized to compile a list of all the LTCFs in District 3-1. DHD is a database used state-wide for data entry of inspection reports for permitted facilities. To encourage CNA participation in the survey, several Environmental Health Specialists (EHS) contacted the facilities through a phone call or site visit to speak with the manager or the person in charge. The EHS stated the purpose of the call and/or visit and provided the name of the EHS who inspects their facility to build and establish rapport. Each EHS involved in the data collection was standardized and provided with a phone prompt and an email template to assist them during the collection process. The results of the survey were tabulated and exported to Microsoft Excel for analysis.
Results
According to the Review Nurse and Trainer with the Georgia Medical Care Foundation, feeding, assisting in hydration, and assisting to feed, such as proper feeding techniques, are personal care skills that are included in the nursing assistant curriculum along with nutrition education. However, food safety is not included in the feeding and assisting to feed skills. In reference to the CNA performance checklist regarding the Federal and State guidelines and skills checklist, provided by the interviewee, all students were required to pass skills at 100% in the laboratory exercises which include identifying diet cards/name cards, documenting meal percentage, proper feeding techniques for dependent residents, documenting Intake & Output, assisting visually impaired residents, and care of skin with feeding tubes all included in the section of the resident’s meal time and hydration skill. In addition, nursing assistants were trained on infection control regarding hand washing procedures with an emphasis on 20 seconds for the entire handwashing process (B. Simmons, personal communications, March 9, 2021).
Fourteen volunteers participated in the survey. As seen in Figure 1, participants were asked questions based on their food safety training while employed at the LTCF regarding the five risk factors. Sixty-four percent of respondents stated that no food safety training was provided, 33% stated they were trained orally regarding food safety while employed at LTCF, and 79% stated they never received training regarding the five risk factors that contribute to foodborne illness. Lastly, one respondent stated they were certified as a Food Handler via ServSafe as they were primarily responsible for assisting in feeding the residents.
Figure 1
Results of the survey regarding CNA Food Safety Training
In regards to the food safety training requirements during the nursing assistant program, 50% of respondents indicated food safety training was not provided while another 38% specified oral training was received from an instructor, and 13% received food handler certification as demonstrated below in Figure 2.
Figure 2
Results of survey regarding CNA Food Safety Training during the nursing assistant program
Certified nursing assistants were also surveyed regarding their personal hygiene practices. One hundred percent of respondents confirmed that bare hand contact was never allowed while handling ready-to-eat foods. While 100% of the respondents utilized soap for hand washing, 86% responded only hand soap is used with no hand sanitizer and 14% indicated hand soap was used followed up with hand sanitizer during their hand washing procedure. Lastly, according to the Georgia Medical Care Foundation, the nursing assistant program is updated every five years and CNAs are required to obtain at least 12 and six hours of continuing education for full and part time employees respectively.
Conclusions
The major conclusion of the study was that food safety training, if available was very limited during the CNA program and while employed at long-term care facilities. In addition, the respondents were not trained regarding the five risk factors that contribute to foodborne illnesses. However, CNAs were trained in proper hand washing procedures during the infection control section, how to assist in the feeding and hydration of long-term care facilities residents and were aware that bare hand contact was not allowed with ready-to- eat foods.
Recommendations
The results of the survey showed that certified nursing assistants received some level of food safety training, however, the level of training they receive is variable from various training programs and long-term care facilities in Georgia’s District 3-1. Therefore, requiring a standardized food safety training program is essential to prevent foodborne illnesses among the long-term care facilities and the following components are recommended:
· Certified nursing assistants should be provided with training in food safety related to their job duties once employed at Long-Term Care Facilities.
· Food safety components and the five risk factors that contribute to foodborne illness should become a part of the certified nursing assistant curriculum when the opportunity for updates to the curriculum occurs every five years.
· Georgia’s Health Department, located in District 3-1, should develop partnerships with long-term care facilities and conduct an annual informational food safety refresher session with employed certified nursing assistants
· Georgia’s Health Department, located in District 3-1, should develop and distribute food safety topics via blogs or newsletters aimed at nursing assistants employed at long term care facilities.
Acknowledgments
I would like to thank all participating nursing homes and their CNAs for the cooperation and efforts for the data collection during this pandemic. Furthermore, I want to express my gratitude to Deanna Crosby from Cobb & Douglas Public Health Epidemiology Department for the outbreak data, the Environmental Health Specialist who contacted and collected email addresses, and to my International Food Protection Training Institute Mentor, Doug Saunders, and the IFPTI instructors and staff for this wonderful opportunity.
References
Centers for Disease Control and Prevention. (2013). Prevent the Spread of Norovirus. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/Features/Norovirus/.
Centers for Disease Control and Prevention. (2018). About Norovirus. Retrieved from https://www.cdc.gov/norovirus/about/index.html
Centers for Disease Control and Prevention. (2018). CDC's National Environmental Assessment Reporting System (NEARS). 2018 Summary Report Georgia.
Digital Health Department Inc. (2021). Digital Health Department.
https://ga.mydhd.com/webadmin/login.cfm?attempt=admin.cfm.
Food and Drug Administration. (2018). FDA Report On the Occurrence of Foodborne Illness Risk Factors in Fast Food and Full Service Restaurants, 2013-2014. Retrieved from https://www.fda.gov/media/117509/download.
Georgia Medicaid Management Information System.(2012). Frequently Asked Questions: Nurse Aide Training Program. Retrieved from
Office of Inspector General. (2002). State Nurse Aide Training: Program Information and Data. Retrieved from https://oig.hhs.gov/oei/reports/oei-05-01-00031.pdf.
Author Note
Sharia Hudson, Environmental Compliance Specialist V
Cobb & Douglas Public Health
This research was conducted as part of the International Food Protection Training Institute’s Fellowship in Food Protection, Cohort IX
Correspondence concerning this article should be addressed to:
Sharia Hudson Cobb & Douglas Public Health, Center for Environmental Health 1650 County Services Parkway SW, Marietta, GA 30008-4010
Sharia.Hudson@dph.ga.gov
*Funding for this statement, publication, press release, etc., was made possible, in part, by the Food and Drug Administration through grant 5U18FD005964 and the Association of Food and Drug Officials. Views expressed in written materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does any mention of trade names, commercial practices, or organization imply endorsement by the United States Government.