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Are Food Service Workers the Leading Cause of Norovirus Outbreaks?
Lindsey Miller
7111859
Pathway Bridge for Biotechnology Technician / ENVR 1305
Cathy Egan
September 2nd 2016

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Introduction
Norovirus is a virus that causes acute gastroenteritis, which is the inflammation
of the stomach and intestines (Norovirus | Symptoms | CDC, 2016). Symptoms include,
but are not limited to: diarrhea, vomiting and nausea (Norovirus | Symptoms | CDC,
2016). An individual will develop symptoms within 12-48 hours after being exposed to
norovirus (Norovirus | Symptoms | CDC, 2016). The recovery time is usually 1-3 days
after symptoms appear (Norovirus | Symptoms | CDC, 2016).
The virus cannot grow on food, which means the contamination level cannot
increase during processing or storage (Chai et al., 2010). However, the virus can still
survive due to a low infectious dose (Chai et al., 2010). Norovirus has a low infectious
dose because it takes only 18 virus particles to infect a person (Norovirus |
Transmission | CDC, 2016). Individuals are the most contagious during the infection,
and the first few days after you recover from norovirus (Norovirus | Transmission | CDC,
2016). Infection can happen due to: eating and drinking contaminated products,
touching surfaces or objects that are contaminated and then touching your mouth, or
having contact with someone who is infected (Norovirus | Transmission | CDC, 2016).
Employees should not go to work for at least 3 days after symptoms stop (Norovirus |
Preventing Norovirus Infection | CDC, 2016).
Noroviruses are relatively resistant (Norovirus | Preventing Norovirus Infection |
CDC, 2016). They can survive temperatures up to 140℉, temperatures below freezing,
quick steaming processes and can remain on surfaces for up to two weeks (Gould et
al., 2014) ; (Norovirus | Preventing Norovirus Infection | CDC, 2016). Most outbreaks

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occur in food service settings like restaurants because of the survivability of the virus
(Norovirus | Transmission | CDC, 2016).
Search Methodology
The search was completed between the dates of August 24th 2016 and August
26th 2016. The search began using the National Collaborating Centre for Methods and
Tools 6S Search Pyramid to gather research evidence. Under the systems section,
there were no results found. Under the summaries section, there were no results found.
Under the synopses of synthesis section, there were two sites used to find potential
research; The Community Guide and Health Evidence. At both sites, the search terms,
“norovirus” and “foodborne illness” were used and yielded 21 and 4 results respectively.
3 results from The Community Guide (CDC resources) aided in the introduction as
definitions and concepts, and 1 result from Health Evidence showed potential as a
relevant article. The article from Health Evidence then turned out to be non-relevant, as
it did not relate to the research question. Continuing down the 6S Pyramid, the
synthesis section showed no results found. Under the synopses of single studies
section, there were no results found. For the single studies section, I used Medline:
OVID (accessed via the Conestoga College LRC). I searched for, “norovirus”, “disease
outbreak”, “food handling” and “foodborne illnesses” within one search. It yielded 983
results. I narrowed my search to articles within the past 3 years, which produced 337
results. From these results, I identified 19 potentially relevant articles and found 7 of
them to be truly relevant. From those 7 articles, I narrowed my search down to 4 strong
articles that met all the critical appraisal criteria for accurate evidence.

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I performed another Medline: OVID search with the terms, “sick policy”, and
“Ontario” in one search. It yielded 37 results. From these results, I identified one
potential article that might be relevant. The article appeared to be a moderate article to
use for the research proposal, since it was classified as “grey literature” (was found as a
word document and not traditionally published).
Critical Appraisal
When critically appraising articles, I used the following 10 questions to guide me
to select appropriate articles for research. The questions are: 1. was there a clear
statement about the aims of research? 2. Is a qualitative methodology appropriate? 3.
Was the research design appropriate to address the aims of research? 4. Was the
recruitment strategy appropriate to the aims of research? 5. Was the data collected in a
way that addressed the research issue? 6. Has the relationship between the researcher
and participants been adequately considered? 7. Have ethical issues been taken into
consideration? 8. was the data analysis sufficiently rigorous? 9. Is there a clear
statement of findings? 10. How valuable is the research?
I narrowed down the 19 articles down to 7 using these questions, because most
articles were not relevant enough to the research question, and did not offer a rigorous
enough data analysis. The 4 articles that I chose to critically appraise met the criteria of
these 10 questions. They had an exceptional data analysis, no bias, and was clear in
terms of the statement and the research statement.
The “grey literature” piece that I found was not sufficient enough to use in the
rapid review because it did not meet the criteria that it was a strong article. It was not

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rigorous with the data analysis, not clear with the research statement and not clear with
the findings.
Limitations of this Rapid Review
This rapid review is a quick assessment of available evidence for this research
topic. Since only four articles successfully passed the critical appraisal, there seems to
be a lack of literature directly related to this research question. More research in the
area of noroviruses and food service workers might help develop a stronger correlation
between the two topics to answer the research question.
Summary
Norovirus causes 65% of all known foodborne illnesses, which is approximately
1.6 million cases of acute gastroenteritis in Canada every year (Yearly food-borne
illness estimates for Canada, 2016). A study from the CDC observed that there is at
least 1 norovirus outbreak reported every day (Hall, et al., 2012). Many outbreaks go
unreported due to the recovery time of the infection being 1-3 days (Norovirus - Fact
Sheet, 2014).
Throughout a 4 year period, one study concluded that approximately 90% of
foodborne norovirus outbreaks came from a food preparation setting, which includes
restaurants, catering and banquet facilities (Gould et al., 2014). Infectious fast food
workers account for approximately 70% of the foodborne norovirus outbreaks, with half
of those instances occuring because of bare hand contact with ready to eat foods
(Gould et al., 2014).

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1 in 5 restaurant food workers reported that they went to work while vomiting or
having diarrhea for at least one shift in the previous year (Gould et al., 2014). A fear of
job loss and financial insecurity were identified as factors that influenced their decision
to stay at work (Gould et al., 2014). It is suggested that the amount of norovirus on a
symptomatic individual versus an asymptomatic individual is similar, meaning that even
if they no longer show symptoms they must stay away from work for the minimum
amount of time (Lin et al., 2015). Food preparation settings must create, and comply
with, policies to prevent infected staff members from returning to work for a minimum of
72 hours after symptoms end (Gould et al., 2014).
Conclusion
Many norovirus outbreaks emerge from food preparation services like
restaurants (Gould et al., 2014). Food workers are identified as the primary source of
contamination because of bare hand contact with ready to eat food (Gould et al., 2014).
Researchers have concluded that there is a growing correlation between norovirus
outbreaks and food handlers (Chai et al., 2010). Solutions that involve job protection
and financial security have potential for stopping further outbreaks of norovirus (Gould
et al., 2014). Norovirus outbreaks have the potential to decrease if food handlers are
more inclined to stay home when they are sick.

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Research Proposal
Introduction
It is suggested that food service workers should stay away from work while being
symptomatic, and for up to three days after symptoms end. However, there are a few
factors that can influence the amount of time a person can take off of work due to being
sick. These factors are job protection and financial security.
The majority of workers in Ontario have access to unpaid sick leave
(Mojtehedzandeh, 2016). However, approximately 1.6 million workers in Ontario do not
have access to a job protected sick day (Mojtehedzandeh, 2016). Under Ontario’s
Employment Standards Act, workers can have up to 10 unpaid emergency leave days
(sickness related or otherwise) (Mojtehedzandeh, 2016). Businesses with less than 50
employees are not covered under this act, and these workers do not get any sick days,
paid or unpaid, and have no job protection (Mojtehedzandeh, 2016).
Research Question
Can the amount of sick days a food service worker has influence their decision to
stay home when they are sick?
Methodology
To answer the research question, there will be a qualitative study done to see if
the amount of sick days given can influence a food service workers willingness to stay
home from work when they are sick. This study will be promoted at college and
university campuses using posters with the study information and available contact

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information. There will also be an email sent out to the students at the campuses to
promote the study. This study will take place as a one on one interview, with individuals
answering yes and no questions as well as short answer. The interview should not take
more than 15 minutes to complete. There is no target age group for the interviews.
Interviews will be held on campus. Before the interview begins, the participant would be
notified of the ethics regarding this survey. After the interview is completed, the
individual would receive an honorarium for their participation. The interviews would be
held over the course of 6 months, and data would be compiled and analyzed as the
interviews are conducted.
Data-Collection Methods
The questions will be as follows: 1. Have you worked with ready-to-eat foods or
have been involved with preparing raw or uncooked foods? (Y/N) 2. Have you ever
gone to work while having the following symptoms: Diarrhea or vomiting? (Y/N) If yes,
why did you feel like you had to still go to work? (Short answer) 3. Have you ever gone
to work 1-2 days after you have had acute gastroenteritis (also known as the stomach
or intestinal flu)? (Y/N) If yes, why did you feel like you still had to go to work? (Short
answer) 4. Are you aware of your workplace’s sick day policies? (Y/N) 5. If you had up
to 10 paid sick days each year, would you take a few days off after having acute
gastroenteritis? (Y/N) 6. Would you be more willing to take unpaid sick days after you
used up your 10 paid sick days if you knew that you would not be at risk of losing your
job? (Y/N)

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Ethics Approval
Participants will be notified immediately that they can back out of the interview at
any point in time where they do not feel comfortable answering the questions.
Participation is strictly voluntary. Individuals will be informed of the study and why it is
being conducted. Individuals will remain anonymous and only their responses will be
used to collect data. This research proposal will be submitted to the research ethics
board and await approval before proceeding.
Analysis
The answers to each question will influence the analysis. Answering yes to some
of the questions would imply that if there was a change to the sick day policy, food
service workers would be more willing to stay home when they are sick. If more food
service workers stayed home when they are sick, foodborne illness outbreaks could
decrease. If the individual explains in the short answer questions that financial security
or job security influenced them to continue to go to work, that would further imply that
the sick day policy in Ontario needs to change.
Schedule
The schedule for the interviews will be as follows:
Week 1 will involve preparing the interviews, honorariums and posters to be
distributed at the college/university campuses. It will also involve sending out emails to
the schools asking if this study can be emailed to all students. Weeks 2-29 will involve
travelling from campus to campus holding interviews, collecting the results and

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analyzing and grouping together the results to see a correlation. Week 30 will involve
making a summary of all the data collected and making a report based on the results.
Budget
The budget will need to include enough honorariums to provide to the individuals
that participate (10$ gift card for each participant). This will fluctuate depending on the
amount of participants that volunteer for this study. This budget will need to include the
travel expenses from going campus to campus. It will also need to include the printing
costs related to the posters as well as distribution.

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References
Chai, L., Hidayah, M., Mohamad Ghazali, F., Son, R., Tunung, R., & Zainazor, C.
(2010). The Scenario of Norovirus Contamination in Food and Food Handlers.
Journal of Microbiology and Biotechnology, 20(2), 229-237. Retrieved from
http://www.jmb.or.kr/journal/viewJournal.html?year=2010&vol=20&num=2&page
=229
Gould, H., Hall, A., Pringle, K., Parashar, U. & Wikswo, M. (2014). Vital Signs:
Foodborne Norovirus Outbreaks — United States, 2009–2012. Morbidity and
Mortality Weekly Report (MMWR), 63(22), 491-495. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a3.htm
Hall, A., Eisenbart, V., Etingüe, A., Gould, L., Lopman, B., & Parashar, U. (2012).
Epidemiology of Foodborne Norovirus Outbreaks, United States, 2001–2008.
Emerg. Infect. Dis., 18(10), 1566-1573. http://dx.doi.org/10.3201/eid1810.120833
Lin, Y., Hipfl, E., Lederer, I., Allerberger, F., & Schmid, D. (2015). A norovirus GII.P21
outbreak in a boarding school, Austria 2014. International Journal of Infectious
Diseases, 37, 25-29. http://dx.doi.org/10.1016/j.ijid.2015.05.021
Mojtehedzandeh, S. (2016). Ontario lagging on paid sick days, leaving low-wage
workers stranded | Toronto Star. Toronto Star. Retrieved 31 August 2016, from
https://www.thestar.com/news/gta/2016/03/22/ontario-lagging-on-paid-sick-days-
leaving-low-wage-workers-stranded.html

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Norovirus | Burden of Norovirus Illness and Outbreaks | CDC. (June 24, 2016). Centers
for Disease Control and Prevention. Retrieved 25 August 2016, from
http://www.cdc.gov/norovirus/php/illness-outbreaks.html
Norovirus - Fact sheet. (2016). Public Health Agency of Canada. (June 3, 2014)
Retrieved 25 August 2016, from http://www.phac-aspc.gc.ca/fs-sa/fs-fi/norovirus-
eng.php
Norovirus | Preventing Norovirus Infection | CDC. (June 24, 2016). Centers for Disease
Control and Prevention. Retrieved 24 August 2016, from
http://www.cdc.gov/norovirus/preventing-infection.html
Norovirus | Symptoms | CDC. (June 24, 2016). Centers for Disease Control and
Prevention. Retrieved 24 August 2016, from
http://www.cdc.gov/norovirus/about/symptoms.html
Norovirus | Symptoms | CDC. (June 24, 2016). Centers for Disease Control and
Prevention. Retrieved 24 August 2016, from
http://www.cdc.gov/norovirus/about/symptoms.html
Yearly food-borne illness estimates for Canada. (July 5, 2016). Healthycanadians.gc.ca.
Retrieved 25 August 2016, from http://healthycanadians.gc.ca/eating-
nutrition/risks-recalls-rappels-risques/surveillance/illness-estimates-estimations-
maladies/yearly-annuel-eng.php