Food Manager Prep / The Big 6 foodborne illnesses

The Big 6 foodborne illnesses

Updated October 2026 · Based on the FDA Food Code 2022 (the edition the exams follow) and the new 2026 edition

Six pathogens get special treatment in the FDA Food Code because they spread easily from a sick worker through food. A food protection manager must know which symptoms employees report, which illnesses go to the health department, and whether to exclude or restrict the worker.

Short answer The Big 6 are norovirus, hepatitis A, Shigella, STEC (Shiga toxin-producing E. coli), typhoid fever (Salmonella Typhi) and non-typhoidal Salmonella. Employees report vomiting, diarrhea, jaundice, sore throat with fever and infected uncovered wounds. The person in charge notifies the health department for jaundice or any Big 6 diagnosis.

The six pathogens

Norovirus	Exposure window: 48 hours from last exposure
Hepatitis A virus	Exposure window: 30 days
Shigella spp.	Exposure window: 3 days
Shiga toxin-producing E. coli (STEC)	Exposure window: 3 days
Typhoid fever (Salmonella Typhi)	Exposure window: 14 days; also reportable if had within the past 3 months without antibiotic therapy
Non-typhoidal Salmonella	Reportable when diagnosed

"Big 6" is exam vocabulary. The Food Code lists these pathogens in 2-201.11(A)(2) without the nickname.

What employees must report

Under 2-201.11(A), food employees and applicants must tell the person in charge about:

Symptoms: vomiting, diarrhea, jaundice (yellow skin or eyes), sore throat with fever, and a pus-containing lesion (boil, infected wound) that is open or draining and not properly covered.
A diagnosis of any Big 6 pathogen.
Past illness: typhoid fever within the past 3 months without antibiotic therapy.
Exposure to a Big 6 pathogen, within the windows in the table above (2-201.11(A)(4) and (5)).

The person in charge then notifies the regulatory authority only when an employee is jaundiced or diagnosed with a Big 6 pathogen (2-201.11(B)).

Exclude or restrict?

Exclude means the person may not work or enter as an employee. Restrict means no work with exposed food, clean equipment, utensils, linens or unwrapped single-service items. "HSP" means a facility serving a highly susceptible population, such as a hospital, nursing home or child day care.

Vomiting or diarrhea	Exclude (unless the cause is noninfectious)
Jaundice within the last 7 days	Exclude
Hepatitis A diagnosis	Exclude
Typhoid fever diagnosis, or within past 3 months	Exclude
Norovirus, Shigella or STEC diagnosed, no symptoms	Exclude if HSP, restrict if not
Non-typhoidal Salmonella diagnosed, no symptoms	Restrict in both cases
Sore throat with fever	Exclude if HSP, restrict if not
Infected wound not properly covered	Restrict
Exposure only, no symptoms	Restrict, and only in a facility serving an HSP

Covering a wound properly: on the hands or wrists, an impermeable cover such as a finger cot plus a single-use glove; on exposed arms, an impermeable cover; elsewhere, a dry, durable, tight-fitting bandage.

Return to work

Vomiting or diarrhea, no diagnosis: back when symptom-free for at least 24 hours, or with a medical note that the cause is not infectious (2-201.13(A)(1)).
Diagnosed with a Big 6 pathogen: reinstatement follows the pathogen-specific conditions of 2-201.13. Check them with your health department before the employee comes back.
Changed in the 2026 Food Code: where testing is required, reinstatement needs two consecutive negative results from a validated test by an accredited or certified lab. The 2022 Food Code said two consecutive negative stool cultures.

The written illness policy (new in 2026)

The 2026 Food Code adds a requirement in 2-501.11: the establishment must have a written employee illness policy covering symptoms, the Big 6, exclusion and restriction, and reinstatement, available on request. Written procedures for cleaning up vomit and diarrhea were already required (2-501.11 in the 2022 code, now 2-502.11). Exams built on the 2022 Food Code may not ask about the new policy yet.

Other rules on sick workers

An employee with persistent sneezing, coughing or a runny nose may not work with exposed food, clean equipment, utensils, linens or unwrapped single-service items (2-401.12).
A foodborne disease outbreak is two or more cases of a similar illness from a common food (1-201.10).
The onset of an apparent outbreak is an imminent health hazard: stop operations and notify the regulatory authority (8-404.11).

Exam traps

Only jaundice and Big 6 diagnoses go to the health department, not every case of diarrhea.
Asymptomatic Salmonella (non-typhoidal) is always restrict, even in a hospital.
The return-to-work clock for vomiting or diarrhea is 24 hours without symptoms.

Practice these with the free practice test.

Frequently asked questions

What are the Big 6 foodborne illnesses?

Norovirus, hepatitis A virus, Shigella, Shiga toxin-producing E. coli (STEC), typhoid fever (Salmonella Typhi) and non-typhoidal Salmonella. A food employee diagnosed with any of them must report it to the person in charge.

Which symptoms must a food employee report?

Vomiting, diarrhea, jaundice, sore throat with fever, and a pus-containing lesion such as a boil or infected wound that is open or draining and not properly covered.

What is the difference between exclusion and restriction?

Exclusion keeps the person from working in or entering the establishment as an employee. Restriction lets them work, but not with exposed food, clean equipment, utensils, linens or unwrapped single-service items.

When can an employee with vomiting or diarrhea return to work?

When they have had no symptoms for at least 24 hours, or with a medical note that the cause is not infectious, provided no Big 6 pathogen was diagnosed.

When must the person in charge notify the health department?

When a food employee is jaundiced or is diagnosed with one of the Big 6. Ordinary diarrhea without a diagnosis does not have to be reported to the regulatory authority.