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Outbreaks of foodborne diseases are of global concern, posing significant impacts on both human health and the economy (1-2). In the USA, an estimated 9.4 million cases of foodborne disease caused by identified pathogens occur annually (3). One of the most prevalent locations for foodborne illness outbreaks is a catering service facility. The estimated cost of a single outbreak of foodborne illness in a restaurant may exceed 1 million US dollar (USD) (4). Research has shown that factors such as inadequate time-temperature control, insufficient kitchen hygiene, and the presence of disease carriers among food handlers in catering service facilities, including restaurants, contribute to foodborne illnesses (5). The primary cause of these outbreaks is often faulty operation. Increasing awareness of food hygiene, etiologies, and contributing factors of foodborne diseases can serve as a guide for preventing foodborne outbreaks (6-7).
The China National Center for Food Safety Risk Assessment established the Foodborne Disease Outbreak Surveillance System (FDOSS) to collect data on foodborne diseases. The CDCs at various levels throughout China are responsible for conducting on-site investigations during outbreaks and entering relevant data into the FDOSS. The purpose of this study is to analyze the epidemiological characteristics of foodborne disease outbreaks occurring in catering service facilities between 2010 and 2020 using data from the FDOSS.
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Between 2010 and 2020, data were gathered on all foodborne disease outbreaks involving two or more patients or at least one death, which occurred in catering service facilities within China, not including Xizang (Tibet) Autonomous Region. These outbreaks were investigated and reported to FDOSS by local CDCs. The information collected included the timing and location of the outbreaks, the number of cases, hospitalizations, and fatalities, as well as the causes, pathogens, and food production environments involved.
Prior to inclusion in the FDOSS database, all outbreak incidents occurring in catering service establishments underwent rigorous auditing and verification by both the prefecture- and the provincial-level CDCs. Data processing and storage were performed using Microsoft Excel 2019 (Microsoft Corporation, Redmond, Washington, USA). For analysis purposes, dichotomous variables were summarized by counts and percentages, whereas continuous variables were represented by means.
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The FDOSS reported a total of 18,331 outbreaks in catering service facilities in China between 2010 and 2020, which resulted in 206,718 cases, 68,561 hospitalizations, and 201 deaths. Among all foodborne outbreaks reported in the same period, these figures accounted for 50.87% of total outbreaks, 75.36% of total cases, 66.04% of total hospitalizations, and 13.65% of total deaths during this period. The median number of patients per outbreak was 15, with a median of 3 hospitalizations per outbreak.
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The number of outbreaks and cases climbed rapidly from 2010 to 2018, with a peak of 3,610 outbreaks and 31,230 cases in 2018. The third quarter demonstrated the highest frequency of outbreaks and cases, while the combined second and third quarters represented 76.12% of annual outbreaks and 72.93% of annual cases (Figure 1).
Figure 1.Number of reported foodborne disease outbreaks and cases in catering service facilities by quarters, China, 2010–2020.
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Pathogenic organisms were the primary cause of outbreaks in southern (55.11%), northwestern (26.51%), eastern (26.40%), central (22.78%), and northern regions of China (20.44%), while toxic animals, plants, and poisonous mushrooms were the leading causes of outbreaks in northeastern (22.49%) and southwestern regions (29.54%), respectively. Chemical-related incidents resulted in the highest number of fatalities in northeastern (87.50%), northwestern (58.33%), central (55.00%), and northern regions of China (30.00%), whereas toxic animals and plants were the leading cause of deaths in southern (47.06%) and eastern regions (29.03%). Poisonous mushrooms accounted for the highest fatality rates in the southwestern region (30.00%).
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The primary factors contributing to outbreak occurrences were pathogenic organisms, accounting for 4,883 (26.64%) outbreaks, 94,047 (45.50%) cases, 32,170 (46.92%) hospitalizations, and 21 (10.45%) deaths. Following this, toxic animals, plants, and mushrooms were responsible for 3,279 (17.89%) outbreaks, 30,698 (14.85%) cases, 12,338 (18.00%) hospitalizations, and 95 (47.26%) deaths (Table 1). Chemical substances, such as methanol and nitrite, caused the majority of fatalities (63). Vibrio parahaemolyticus, Salmonella spp. (species), and Staphylococcus aureus were the most prevalent pathogens, resulting in 3,333 outbreaks, 60,520 cases, 21,491 hospitalizations, and 9 deaths. The susceptibility of various food types to outbreaks was multifaceted, with meat products, aquatic goods, and vegetables associated with 2,724 (14.86%), 1,595 (8.70%), and 1,571 (8.55%) outbreaks, respectively, between 2010 and 2020.
Pathogenic Factor Outbreak Proportion
(%)Case Proportion
(%)Hospitalization Proportion
(%)Death Proportion
(%)Pathogenic organism Vibrio parahaemolyticus 1,638 8.94 26,180 12.66 5,749 8.39 2 1.00 Salmonella spp. 1,118 6.10 25,248 12.21 12,027 17.54 5 2.49 Staphylococcus aureus 577 3.15 9,092 4.40 3,715 5.42 2 1.00 Bacillus cereus 347 1.89 7,432 3.60 2,585 3.77 1 0.50 Escherichia coli 308 1.68 6,842 3.31 2,468 3.60 1 0.50 Others 895 4.88 19,253 9.31 5,626 8.21 10 4.98 Toxic animals and plants 1,816 9.91 22,615 10.94 8,142 11.88 49 24.38 Poisonous mushrooms 1,463 7.98 8,083 3.91 4,196 6.12 46 22.89 Chemicals 616 3.36 7,564 3.66 5,076 7.40 63 31.34 Mycotoxin 5 0.03 103 0.05 46 0.07 1 0.50 Parasite 11 0.06 125 0.06 10 0.01 0 0.00 Other factors 1 0.01 2 0.00 0 0.00 0 0.00 Unknown reasons 9,536 52.02 74,179 35.88 18,921 27.60 21 10.45 Total 18,331 100.00 206,718 100.00 68,561 100.00 201 100.00 Table 1. Foodborne disease outbreaks, cases, hospitalizations, and deaths by pathogenic factors in catering service facilities, China, 2010–2020.
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Catering service facilities encompass a range of establishments, including restaurants, street vendors, canteens, food stores, and rural banquets. Between 2010 and 2020, foodborne disease outbreaks in these facilities accounted for 5,607 (30.59%) incidents in restaurants, 2,876 (15.69%) in street vendors, and 2,560 (13.97%) in staff canteens (Figure 2). Among all catering service facilities, rural banquets and street vendors were associated with the highest mortality rates, with 64 (31.84%) and 34 (16.92%) deaths, respectively.
Figure 2.Reported foodborne disease outbreaks in catering service facilities by setting and causative factors in China, 2010–2020.
A cross-tabulation analysis revealed that the leading causes of outbreaks in restaurants were incorrect processing (655), accidental ingestion (263), and cross-contamination (240). Conversely, the primary causes of outbreaks in street vendors were accidental ingestion (775), improper storage (250), and inadequate processing (227). Similarly, staff canteens experienced outbreaks mainly due to undercooking (737), accidental ingestion (369), and improper processing (191). The majority of deaths resulted from accidental ingestion (89) and improper processing (35).
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Using a multidimensional analysis approach, we identified outbreaks by determining pathogenic factors and associated food sources, comparing them with the corresponding settings, and selecting combinations responsible for more than 50 outbreaks. Our analysis revealed that aquatic products contaminated with Vibrio parahaemolyticus at restaurants (resulting in 342 outbreaks and 5,345 cases) and rural banquets (leading to 110 outbreaks and 2,062 cases), as well as bean poisoning caused by Phaseolus vulgaris in staff canteens (triggering 725 outbreaks and 9,739 cases), were the primary contributors to food-borne disease outbreaks in catering operations (Table 2).
Settings Pathogenic factor Suspicious food Outbreak Case Hospitalization Death Restaurant Vibrio parahaemolyticus Aquatic products 342 5,345 1,582 0 Poisonous mushrooms Mushrooms 175 1,107 550 0 Salmonella spp. Meat products 93 2,345 1,365 0 Bean poisoning Phaseolus vulgaris 87 718 231 0 Staff canteen Bean poisoning Phaseolus vulgaris 725 9,739 2,812 0 Poisonous mushrooms Mushrooms 249 1,783 899 15 Street vendor Poisonous mushrooms Mushrooms 622 2,322 1,118 10 Bean poisoning Phaseolus vulgaris 75 415 123 0 Nitrite Meat products 54 320 245 3 Salmonella spp. Egg foods 54 269 196 0 Farmers market Poisonous mushrooms Mushrooms 256 995 559 6 Rural banquet Vibrio parahaemolyticus Aquatic products 110 2,062 387 0 Salmonella spp. Meat products 101 3,603 2,482 2 Poisonous mushrooms Mushrooms 58 1,240 789 9 School canteen Bean poisoning Phaseolus vulgaris 73 1,931 712 0 Bacillus cereus Flour and rice products 51 1,489 751 0 Fast food store Salmonella spp. Cakes and pastries 58 1,035 525 0 Table 2. Multidimensional analysis of settings, pathogenic factors, and food sources in foodborne disease outbreaks at catering service facilities in China, 2010–2020.
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Due to shifts in dietary patterns and the fast-paced nature of modern life, an increasing number of individuals have opted to dine at foodservice establishments in recent years. Consequently, these establishments have become the leading source of foodborne disease outbreaks in numerous regions. It has been documented that a variety of food safety risks exist in foodservice facilities, such as restaurants, including those associated with food ingredients, handling practices, storage, and transportation. These risks may contribute to the occurrence of foodborne disease outbreaks. Moreover, the number of cases and hospitalizations associated with each outbreak at these facilities tends to surpass those resulting from household settings, ultimately leading to a more significant disease burden.
In recent years, there has been a steady increase in the number of foodborne disease outbreaks and cases in catering service facilities due to the expansion of the reporting network. However, in 2020, there was a decrease in these incidents, with the primary pathogenic factor, Vibrio parahaemolyticus, dropping from first to second place, being replaced by Salmonella spp. This shift may be attributed to the impact of coronavirus disease 2019 (COVID-19) and its related prevention and control measures, which reduced the number of residents gathering and dining outside. Additionally, the decline in consumption of cold-chain transported aquatic products may have also played a role in this trend.
The peak of outbreaks and cases in catering service facilities occurred annually during the second and third quarters, aligning with the period of bacterial foodborne disease epidemics. This may be attributed to the increased temperature and humidity during this season, promoting bacterial growth and reproduction. Vibrio parahaemolyticus, Salmonella spp., and Staphylococcus aureus, the primary pathogens associated with outbreaks in food service facilities, also demonstrated increased activity during the summer and autumn. Concurrently, meat and aquatic products contaminated with bacteria were more prone to spoilage. The higher number of outbreaks and cases in eastern China may result from economic growth and a heightened focus on epidemiological investigations. Similar epidemiological characteristics have been observed in foodborne disease outbreaks in coastal regions (provinces, autonomous regions, and municipalities directly under the Central Government with coastline) (8-9). The findings suggest that targeted population education should be reinforced in catering service facilities in China.
Various pathogenic agents and food combinations, including Vibrio parahaemolyticus-contaminated aquatic products and Salmonella-contaminated meat items, have been found to be susceptible to causing outbreaks of foodborne illnesses in catering establishments. The primary causes of these outbreaks were related to food preparation management, such as improper processing, accidental consumption, and cross-contamination. Despite the presence of food safety management systems in many restaurants and cafeterias, their implementation was not always effective. To address this issue, it is recommended that the responsible departments enhance food safety management efforts among street vendors and rural banquets.
Accidental consumption of toxic mushrooms by Chinese families has been identified as a major cause of fatalities (10). Ingesting harmful chemicals, such as methanol and nitrite, along with poisonous mushrooms and improper food processing, contributed to most deaths in catering service facilities. This situation warrants the attention of authorities, as swift intervention could mitigate the related challenges.
Numerous interventions have demonstrated high effectiveness; thus, it is essential to implement control measures that integrate population science and management. Such measures include public health education on foodborne diseases in catering service facilities and regular food safety training for restaurant employees and managers. By mitigating cross-contamination and ensuring proper cooking and storage practices, the comprehensive implementation of exemplary sanitation procedures during food processing should decrease the incidence of foodborne disease outbreaks (11).
While there remain unidentified causes for numerous instances in the system, the data analyzed may not encompass all actual outbreaks. A thorough examination of high-risk factors necessitates an accurate attribution analysis, which relies on the collection of more specific information and samples throughout the investigation. Alternatively, the rapid detection technology of multi-pathogens, along with pulsed-field gel electrophoresis and whole-genome sequencing, could potentially enhance the laboratory diagnostic capabilities for outbreaks and provide confirmation for the results of epidemiological inquiries (12).
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All members at all participating CDCs.
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No conflicts of interest.
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Temporal Distribution
Geographic Distribution
Pathogenic Factors
Setting of Food Preparation
Combinations of Factors
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