Importance of food defense in hospitals and its role in health security: A systematic review

Food defense in hospital settings encompasses strategies aimed at preventing intentional contamination, sabotage, or bioterrorist threats within institutional food systems. Hospitals are particularly vulnerable due to centralized food preparation and a high proportion of immunocompromised patients. The primary objective of this systematic review is to evaluate the current state of hospital preparedness against intentional food contamination and to identify critical operational and policy gaps in healthcare food security. A systematic literature review was carried out following the PRISMA 2020 guidelines. An extensive search was conducted across multiple databases, including PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar, encompassing publications from January 2000 through July 2025. Grey literature sourced from international and governmental bodies such as the WHO, FDA, and USDA was additionally incorporated to ensure relevant policy frameworks were adequately represented. Studies were eligible for inclusion if they specifically examined intentional food contamination occurring within healthcare or institutional settings. Conversely, studies that focused exclusively on unintentional food safety incidents or were conducted in non-institutional contexts such as retail environments or agricultural sectors were excluded from the review. A total of 13 studies and institutional reports satisfied the inclusion criteria and were subsequently retained for analysis. The methodological quality of the included studies was evaluated using two validated appraisal instruments: the Mixed Methods Appraisal Tool (MMAT) and the AXIS Critical Appraisal Tool. Key vulnerabilities identified included centralized kitchen operations, limited physical access controls, high staff turnover, and the absence of food defense requirements in hospital accreditation standards. While validated tools like the FDA’s Food Defense Plan Builder are available, their implementation in clinical settings remains inconsistent. Documented, though rare, incidents of insider-driven contamination highlight the potential for high-impact events in healthcare facilities. Food defense must be transitioned from an optional practice to a core element of hospital risk management and disaster preparedness. Integrating mandatory vulnerability assessments and targeted staff training is essential to strengthen health system resilience. However, the limited number of peer-reviewed articles specifically focused on hospitals remains a significant constraint for evidence-based policy development.