What the Big 6 are
"Big 6" is the shorthand food safety courses and health departments use for the six agents in the FDA Food Code's employee health section. Under Food Code 2022 section 2-201.11(A)(2), a food employee must report to the person in charge if they have an illness diagnosed by a health practitioner due to:
- Norovirus
- Hepatitis A virus
- Shigella spp.
- Shiga toxin-producing Escherichia coli (STEC)
- Salmonella Typhi (typhoid fever)
- Salmonella (nontyphoidal)
(FDA Food Code 2022, section 2-201.11.) The Big 6 is a list of illnesses that trigger reporting, exclusion or restriction of employees. It is not a ranking of every foodborne hazard. Many other organisms, including Listeria, Clostridium perfringens and Campylobacter, cause foodborne illness but are not on this list.
If the person in charge learns that an employee is jaundiced or has been diagnosed with one of these illnesses, the Food Code adds a duty to notify the regulatory authority (section 2-201.11(B)). Your jurisdiction may adopt a different edition of the Food Code, so confirm local rules.
Reportable symptoms are a separate list
The same section lists reportable symptoms: vomiting, diarrhea, jaundice, sore throat with fever, and an open or draining lesion containing pus (section 2-201.11(A)(1)). A food employee with vomiting or diarrhea is excluded under section 2-201.12(A). Jaundice with onset in the last 7 calendar days also means exclusion, unless the employee provides written medical documentation (section 2-201.12(B)). On the exam, keep the six diagnoses and the five symptoms apart.
Norovirus
CDC says norovirus is "the leading cause of vomiting and diarrhea, and foodborne illness in the United States." Symptoms are diarrhea, vomiting, nausea and stomach pain, usually starting 12 to 48 hours after exposure. Infected people can spread it by preparing food, and CDC advises staying home for 2 days (48 hours) after symptoms stop. (CDC: About norovirus)
Controls: wash hands well and often, and exclude ill employees as the Food Code requires.
Hepatitis A virus
Hepatitis A is a liver disease. Symptoms, when they appear, can include dark urine or clay-colored stools and yellow skin or eyes (jaundice), usually 2 to 7 weeks after exposure. CDC says the best way to prevent it is vaccination, and good hand hygiene also helps. (CDC: About hepatitis A)
Exam link: jaundice is a reportable symptom, and a diagnosis with hepatitis A virus is a reportable diagnosis.
Shigella
CDC says symptoms usually start 1 to 2 days after infection and last about 7 days: diarrhea (which may be bloody), fever and stomach pain. "Swallowing just a small amount of Shigella germs can make you sick," and it can spread through contaminated food or water, or contact with a sick person. (CDC: About shigella)
Controls: handwashing with soap and water at key times, and exclusion of ill employees.
Shiga toxin-producing E. coli (STEC)
STEC infection can lead to hemolytic uremic syndrome (HUS), which CDC says "can lead to kidney failure, permanent health problems, and even death." People can be infected by swallowing the bacteria through contaminated food or water, or through contact with animals or other people. Children under 5 and adults 65 and older are at higher risk. (CDC: About E. coli)
STEC includes E. coli O157:H7 and other serotypes. The Food Code names the group "Shiga toxin-producing Escherichia coli", not only O157:H7.
Salmonella Typhi
Salmonella Typhi causes typhoid fever. CDC says it spreads through feces, and that infection can occur through "food handled by someone who didn't wash their hands after using the bathroom." People who have recovered can still carry the bacteria. Most U.S. cases involve international travel. (CDC: Typhoid fever)
The Food Code treats typhoid separately from other Salmonella, including a reportable past illness of typhoid fever within the past three months (section 2-201.11(A)(3)).
Salmonella (nontyphoidal)
These are the Salmonella types that cause diarrheal illness. CDC says contaminated food is the source of most of these illnesses and that "Chicken is a major source of Salmonella infection." (CDC: About Salmonella)
Separate topic: Listeria is not a Big 6 pathogen
Listeria monocytogenes is a real and serious hazard, but it is not one of the six reportable agents. It matters for a different reason: the FDA says it "can survive and grow even under refrigeration," so refrigeration alone does not control it. (FDA: Listeria) CDC lists pregnant women, newborns, adults 65 and older, and people with weakened immune systems as higher risk. (CDC: About Listeria)
Exam questions about Listeria usually come under date marking and cold holding of ready-to-eat food, not under employee illness reporting.
Sample exam questions
Question 1: Which of these is NOT one of the Big 6 reportable agents? Norovirus, Shigella, Hepatitis A virus, Listeria monocytogenes. Answer: Listeria monocytogenes.
Question 2: A cook is diagnosed with Shigella infection. Who must the cook tell? Answer: the person in charge (Food Code 2-201.11(A) and (E)).
Question 3: An employee has jaundice that began 3 days ago. What does the Food Code require? Answer: exclusion from the establishment unless written medical documentation shows the jaundice is not from hepatitis A virus (2-201.12(B)).
Closing note
Memorize the six exactly as the Food Code lists them, and know which symptoms and diagnoses lead to exclusion or restriction. For your exam, follow the Food Code edition your jurisdiction has adopted and your course materials.