How to Conduct an Allergen Gap Assessment 

Reviewed and Approved by Tim Lombardo, Senior Director, Food Consulting Services, EAS Consulting Group (A Certified Group Company) 

1-Minute Summary 

  • Over half of U.S. FDA food recalls in 2023 were due to undeclared allergens, underscoring a significant challenge in allergen control within the industry. 
  • Allergen Gap Assessments are essential for identifying and addressing weaknesses in allergen management in food production, as required by 21 CFR 117. 
  • Compliance with key regulations like FSMA, FALCPA, and the FASTER Act is crucial, with Allergen Gap Assessments playing a pivotal role in ensuring adherence and identifying potential allergen-related hazards. 
  • Conducting an Allergen Gap Assessment involves gathering regulatory documents, creating a checklist, evaluating processes, documenting gaps, and developing corrective actions, with annual assessments recommended to maintain compliance and adapt to changes. 

 


 

More than a decade after enactment of the Food Safety and Modernization Act (FSMA), the industry is still struggling to implement effective allergen controls. In fact, in 2023, 54% of U.S. FDA food recalls were due to undeclared allergens. Meanwhile, 36% of USDA recalls were for the same reason.  

While most issues with undeclared allergens are unintentional, the industry still must improve its understanding of allergen controls so we can work together to reduce recalls related to undeclared allergens.  

One vital tactic is to perform an Allergen Gap Assessment in your facility. It’s not only a regulatory requirement under 21 CFR 117, it’s good business to maximize safety for your customers. In this article, we explain how to perform an Allergen Gap Assessment.  

What is an Allergen Gap Assessment? 

An Allergen Gap Assessment is a systematic process used to identify and address potential weaknesses in allergen management within food production facilities

Definition of Allergen Gap Assessment

 

It involves a thorough review of the entire manufacturing process, from ingredient procurement to product distribution, with a focus on points where allergens could be unintentionally introduced or inadequately controlled.  

Understanding Critical U.S. FDA Regulations for Allergen Control Programs 

Food Safety Modernization Act (FSMA) 

Key regulations include the Food Safety Modernization Act (FSMA), enacted in 2011, which marked a significant shift in food safety approaches, emphasizing prevention over reaction. To implement FSMA, the FDA has established nine rules, including the vital Preventive Controls for Human Food: Current Good Manufacturing Practice, Hazard Analysis, and Risk-Based Preventive Controls for Human Food (21 CFR 117) 

This rule mandates that all food facilities, both domestically and internationally, conduct hazard analyses to pinpoint food safety risks such as the introduction of allergens and create risk-based preventive controls. Implementing comprehensive allergen control programs forms a core part of this hazard prevention strategy. 

EAS Consulting Group independent consultant Steven Gendel, Ph.D, answers 5 questions food producers need to understand about allergen controls here 

Food Allergen Labeling and Consumer Protection Act (FALCPA) 

In addition to FSMA, the Food Allergen Labeling and Consumer Protection Act (FALCPA) plays a critical role in allergen management. It requires the allergen to be listed using its common name, making preventive allergen controls a necessary part of your process. 

Food Allergy Safety, Treatment, Education, and Research (FASTER) Act 

The 2021 FASTER Act further expanded the scope of allergen awareness by recognizing sesame as the ninth major U.S. food allergen: 

  • Milk 
  • Eggs 
  • Fish 
  • Crustacean shellfish 
  • Tree nuts 
  • Peanuts 
  • Wheat 
  • Soybeans 
  • Sesame 

For food manufacturers, understanding and integrating these regulations into your allergen control programs is paramount. To help, the FDA has issued several guidance documents to aid industry professionals in developing robust allergen controls.   

Regular Allergen Gap Assessments are instrumental in ensuring compliance with these regulations. Such assessments facilitate the identification of potential allergen-related hazards and verify that effective preventive measures are in place, adhering to the Hazard Analysis and Risk-Based Preventive Controls (HARPC) approach required by FSMA. 

How Do I Conduct an Allergen Gap Assessment? 

System breakdowns can occur at any point in your supply chain and manufacturing process, allowing undeclared allergens to contaminate products. In addition, gathering all the resources and understanding all the regulations is daunting.  

The best place to start is by conducting an Allergen Gap Assessment. The following outlines how to conduct this assessment, along with examples to illustrate the process. 

Step 1: Gather Documents 

Collect all relevant regulatory documents, including… 

Step 2: Create an Allergen Gap Assessment Checklist 

  • Develop a checklist to capture each requirement given in the regulations and your third-party audit standard (if applicable). Below is a simple example: 

21 CFR 117 Regulation

Description

Observations

Gaps

21 CFR 117.20 
Plant and Grounds 
 
21 CFR 117.80 
Processes and Controls 

 
21 CFR 117.135 
Preventive Controls 

Allergen Management 

  • Supplier Approval 
  • Ingredient Receipt 
  • Ingredient Storage  
  • Mixing 
  • Baking 
  • Packaging 
  • Labeling 
  • Finished Goods Storage  
  • Training 
  • GMPs 
  • Airflow/Filtration 
  • Recordkeeping 

 

 

21 CFR 117.35 

Sanitary Operations 

 

21 CFR 117.37 

Sanitary Facilities and Controls 

 

21 CFR 117.40 

Equipment and Utensils 

 

21 CFR 117.80 

Processes and Controls 

 

21 CFR 117.135 

Preventive Controls 

Cleaning and Sanitation 

  • Manual Cleaning  
  • CIP Cleaning 
  • Visual Inspection 
  • Swabbing 
  • Swab +/- Controls 
  • Verification Activities 
  • Validation Activities 
  • Training 
  • Recordkeeping 

 

 

 

 

Step 3: Conduct the Allergen Gap Assessment 

Unlike pathogens, allergens cannot be removed at a critical control point. It’s vital to examine your entire process.  

Include All Processing Steps: 
  • Cover each step from ingredient receipt to finished product storage
  • Focus on allergen movement potential throughout the process
Ingredient and Supplier Review:
  • Examine procurement of ingredients and sub-ingredients
  • Note allergens not in your ingredients but present at the supplier's facility
  • Review R&D ingredients not used in production, if applicable
Processing Step Evaluation: 
  • Analyze how ingredients are handled, weighed, mixed, and stored
Assess Facility Airflow, Dust Collection, and Traffic Flow Involving: 
  • Production and transient employees (quality control, maintenance, etc.) 
  • Ingredient movement 
  • Work-in-progress and finished products 
  • Trash removal 
  • Verify Preventive Control activities as per the Food Safety Plan
Good Manufacturing Practices (GMPs) Assessment: 
  • Check for color-coded utensils usage
  • Evaluate handwashing, uniform exchanges, and traffic patterns
Cleaning Procedure Review: 
  • Inspect cleaning procedures, chemicals used, and their concentrations
  • Conduct visual inspections and swabbing for verification
  • Review equipment disassembly and maintenance protocols
Allergen Swab Testing: 
  • Analyze allergen swab sample sites, sampling frequency, and justifications
  • Evaluate verification and validation data, including action limits and corrective actions
Corrective Action/Preventive Action Plan Review: 
  • Assess the facility's system for corrective and preventive actions 

 

Step 4: Document the Gaps 

Note all observations for each section on the Allergen Gap Assessment Checklist. Based on the appropriate standard, note any gaps. Some may be present at multiple stages, which can be combined in your corrective action plan.  

21 CFR 117 Regulation 

 Description 

 Observations 

 Gaps 

21 CFR 117.20 
Plant and Grounds 
 
21 CFR 117.80 
Processes and Controls 

 
21 CFR 117.135 
Preventive Controls 

Allergen Management 

  • Supplier Approval 
  • Ingredient Receipt 
  • Ingredient Storage  
  • Mixing 
  • Baking 
  • Packaging 
  • Labeling 
  • Finished Goods Storage  
  • Training 
  • GMPs 
  • Air Flow/Filtration 
  • Recordkeeping 

SOP 123 (Allergen Control Program) in use. 

Peanuts and soy present. 

Red smocks used in allergen-production areas. 

Allergens managed via production schedules.  

4 allergen swabs verify sanitation after cleaning. 

Finished-good label verification completed.  

No assessment of allergen swab number and placement for sanitation verification. 

No use of boot covers or dedicated boots in allergen areas. 

Allergen training lacks mention of incidental contamination from employee meals. 

Allergen label checks not classified as Preventive Control. 

21 CFR 117.35 

Sanitary Operations 

 

21 CFR 117.37 

Sanitary Facilities and Controls 

 

21 CFR 117.40 

Equipment and Utensils 

 

21 CFR 117.80 

Processes and Controls 

 

21 CFR 117.135 

Preventive Controls 

Cleaning and Sanitation 

  • Manual Cleaning  
  • CIP Cleaning 
  • Visual Inspection 
  • Swabbing 
  • Swab +/- Controls 
  • Verification Activities 
  • Validation Activities 
  • Training 
  • Recordkeeping 

 

ABC Chemical supplies chemicals.  

Operators clean equipment and their areas, while two sanitarians handle common areas.  

Cleaning and sanitizing of parts and utensils occurs in a central washroom, with equipment parts dried using a HEPA-filtered air dryer. 

SOP 234 outlines general cleaning procedures.  

Annual employee training is provided.  

Post-cleaning includes visual checks and 4-5 ATP swabs. 

Allergen swabbing is limited to 1 location.   

No positive and negative controls conducted for swab.    

Swab test kit has not been calibrated for 6 months. 

 

Step 5: Address the Gaps 

Next, conduct a root cause analysis and develop a Corrective and Preventive Action Plan, or CAPA. A common approach is the “5 Whys” approach, which requires asking "Why?" five times to uncover the root cause. Alternatively, the Fishbone (Ishikawa) diagram visually traces cause and effect, guiding through branched paths to pinpoint the problem's source. 

Here is an example:

21 CFR 117 Regulation 

Gap 

Root Cause 

Corrective & Preventive Action 

Due By 

Responsible

21 CFR 117.20 
Plant and Grounds 
 
21 CFR 117.80 
Processes and Controls 

 
21 CFR 117.135 
Preventive Controls 

No use of boot covers or dedicated boots in allergen areas. 

Previous hazard analysis and risk assessment failed to account for appropriate footwear and potential for boots to introduce allergens to the area.  

Update Food Safety Plan to include potential incidental allergen contamination from footwear. 

Update GMP procedure to include use of boot covers. 

Update Annual GMP Refresher training. 

Conduct 1-Point Lesson training for all employees. 

May 1, 2024 

Tim L.  

John B.  

 

Step 6: Ensure the CAPA Plan Includes the Following:

Processing Controls: 

  • Implement process scheduling, traffic control, and air filtration
  • Design facilities and tools to minimize allergen cross-contact

Education and Training: 

  • Train staff in allergen identification and cross-contact prevention

Receiving and Storage Controls: 

  • Check labels and ingredients on receipt 
  • Use clear allergen labels and segregate allergen-containing materials

Production Scheduling: 

  • Separate allergen and non-allergen product runs

Supplier Audits: 

  • Conduct detailed audits of suppliers' allergen controls and ingredient specifications

 

Step 7: CAPA Verification Review 

Effectiveness checks in CAPA plans validate solutions and reduce recurrence risks by ensuring that identified problems are fully resolved. Key methods for effective checks include: 

  • Trend Analysis: Analyze data over time to see if issues like human error or cleaning inefficiencies reoccur post-correction. 
  • Periodic Checks: Schedule regular reviews by quality units on remediated processes, like observing updated footwear practices in allergen-sensitive areas. 
  • Surprise Audits: Conduct unexpected audits to ensure adherence to documented corrective actions in CAPAs. 
  • Sampling: Use sampling and testing, especially during allergen changeovers, to confirm cleaning efficiency and environmental control. 

It's crucial to implement multiple checks over time for thorough verification, as CAPAs often address complex issues requiring more than just simple updates or retraining. Plus, verification must be documented, like in this example: 

21 CFR 117 Regulation 

Gap 

Verification of Effectiveness 

Due By 

Responsible

11 CFR 117.20 
Plant and Grounds 
 
21 CFR 117.80 
Processes and Controls 

 
21 CFR 117.135 
Preventive Controls 

No use of boot covers or dedicated boots in allergen areas. 

Verify Food Safety Plan, GMP procedure, and annual training material have been updated.   

 

Review 1-Point Lesson with 5 employees to determine understanding. 

Aug. 1, 2024 

  1. Amy S. 
  1. Kikey B.  

 

How Often Should Allergen Gap Assessments Be Conducted in Food Facilities? 

The frequency of conducting Allergen Gap Assessments in food facilities is not universally fixed but should be determined based on several factors, including… 

  • Size of the operation 
  • Complexity of the manufacturing processes 
  • Diversity of products manufactured 

As a best practice, it’s advisable to conduct these assessments annually or whenever there are significant changes in the production process, raw materials, or regulatory requirements. 

For example, facilities that introduce new products or change suppliers might face different allergen risks, necessitating a fresh assessment. Similarly, regulatory updates require reassessments to ensure ongoing compliance. 

Get Help With Your Allergen Gap Assessment 

If you need help with your assessment, contact our regulatory consulting arm, EAS Consulting Group, for assistance; our industry experts are happy to help you develop your program.  

If you need allergen testing, Certified Laboratories and Food Safety Net Services (FSNS), both Certified Group companies, can provide what you need.  

Topics: Food & Beverage, Allergen controls