State Foodborne Illness Surveillance and Response Laws: Compilation and Analysis

Objective

To document and assess the variation in state legislation relating to foodborne disease surveillance and outbreak response for all 50 states and the District of Columbia by creating a database and appendix of laws and regulations that will be made available to researchers and policymakers.

Introduction

Foodborne illnesses sicken 48 million and kill 3,000 Americans every year, presenting an enduring threat to the public’s health. In just the past three years alone, the United States has experienced at least four major multistate outbreaks in food. Despite this growing problem, efforts to prevent foodborne illness pose a particular public health challenge due in part to the widely variable laws governing foodborne illness surveillance and outbreak response. The recent passage of the Food Safety Modernization Act (FSMA) presents an opportunity for researchers, program managers, and policy makers to assess and correct the legal barriers that may hinder states in effectively implementing the FSMA’s vision with regard to increased state and local capacity for surveillance and outbreak response.

Methods

We conducted a systematic review and analysis of laws and regulations relating to foodborne illness surveillance and outbreak response in all 50 states and the District of Columbia, using the following methods: (1) we created a database to record state laws and regulations relating to foodborne illness surveillance and outbreak response in all 50 states and the District of Columbia; (2) we conducted a basic gap analysis of state foodborne illness surveillance and outbreak response laws and policies collected in the database; and (3) we conducted case study analyses of previous multistate outbreaks from 2008–2011.

Results

Through compilation of the state foodborne illness surveillance and outbreak response laws and regulations and analysis of previous multistate outbreaks, we are able to present trends, variations, and gaps in the legislation that directly impacts the ability of public health officials to conduct foodborne outbreak investigations. We also present policy recommendations for strengthening state laws and regulations.     

Impact of a Letter-Grade Program on Restaurant Sanitary Conditions and Diner Behavior in New York City

Objectives. We evaluated the impact of the New York City restaurant letter-grading program on restaurant hygiene, food safety practices, and public awareness.Methods. We analyzed data from 43 448 restaurants inspected between 2007 and 2013 to measure changes in inspection score and violation citations since program launch in July 2010. We used binomial regression to assess probability of scoring 0 to 13 points (A-range score). Two population-based random-digit-dial telephone surveys assessed public perceptions of the program.Results. After we controlled for repeated restaurant observations, season of inspection, and chain restaurant status, the probability of scoring 0 to 13 points on an unannounced inspection increased 35% (95% confidence interval [CI] = 31%, 40%) 3 years after compared with 3 years before grading. There were notable improvements in compliance with some specific requirements, including having a certified kitchen manager on site and being pest-free. More than 91% (95% CI = 88%, 94%) of New Yorkers approved of the program and 88% (95% CI = 85%, 92%) considered grades in dining decisions in 2012.Conclusions. Restaurant letter grading in New York City has resulted in improved sanitary conditions on unannounced inspection, suggesting that the program is an effective regulatory tool.Restaurant food safety is increasingly important, with almost half of the US food dollar spent on restaurant food1 and about one third of caloric intake from foods prepared outside the home.2 In New York City (NYC), residents eat out nearly 1 billion times each year.3 Although most diners do not get sick, foodborne pathogens cause millions of preventable illnesses in the United States annually.4 The exact proportion of restaurant-attributable foodborne illness is unknown, but national surveillance in the United States found that two thirds of reported foodborne outbreaks from 1998 through 2008 occurred in the restaurant or deli setting,5 and consumption of food prepared outside the home has been linked to an increased risk of sporadic foodborne diseases.6Regular inspection of restaurants for food safety is a core function of local health authorities, guided by the US Food and Drug Administration (FDA) Food Code.7 Although all states have sanitation codes modeled after the FDA Food Code,8 implementation methods vary by jurisdiction. The NYC Department of Health and Mental Hygiene (hereafter, Health Department) is charged with inspecting restaurants, coffee shops, bars, nightclubs, employee or university cafeterias, bakeries, and fixed-site food stands (hereafter, restaurants). Its inspection program uses a scoring system to measure compliance with the NYC Health Code, which is updated regularly to maintain consistency with the FDA Food Code and the New York State Sanitary Code. Restaurants are entitled to an impartial review of inspection results by an administrative tribunal, which can improve an assigned score and reduce associated monetary fines.Before letter grading, the Health Department aimed to inspect restaurants at least once per year and imposed monetary fines for violations cited at inspections. Inspection results were available on the Health Department Web site. However, financial disincentives and the Web site posting were insufficient to drive improvements across the industry, with most restaurants cited for multiple public health hazards. Mean inspection scores and restaurant sanitary conditions were stagnant (D. Kass, email communication, February 2009).In an effort to improve restaurant food safety and increase transparency of inspection information, the Health Department launched its letter-grade program on July 27, 2010. The program uses public disclosure of inspection scores in the form of letter grades at point of decision-making; a more finely tuned, risk-based inspection schedule; and financial incentives to encourage high food-safety standards. It began after an 18-month planning process that included a public announcement of the intent to begin letter grading; meetings with restaurant industry representatives, food safety experts, and regulators from a jurisdiction with a restaurant sanitary grade program; promulgation of 2 regulations subject to notice and comment; and training and education for restaurateurs. The process was covered by the media, and by July 2010, restaurateurs were aware of the program and anticipating the launch.9,10We evaluated the impact of the restaurant letter-grade program by assessing (1) hygiene and food-safety practices as characterized by inspection outcomes before and after program implementation and (2) public response to the program measured by 2 population-based telephone surveys.     

Food Safety Informatics: A Public Health Imperative

To date, little has been written about the implementation of utilizing food safety informatics as a technological tool to protect consumers, in real-time, against foodborne illnesses. Food safety outbreaks have become a major public health problem, causing an estimated 48 million illnesses, 128,000 hospitalizations, and 3,000 deaths in the U.S. each year. Yet, government inspectors/regulators that monitor foodservice operations struggle with how to collect, organize, and analyze data; implement, monitor, and enforce safe food systems. Currently, standardized technologies have not been implemented to efficiently establish “near-in-time” or “just-in-time” electronic awareness to enhance early detection of public health threats regarding food safety. To address the potential impact of collection, organization and analyses of data in a foodservice operation, a wireless food safety informatics (FSI) tool was pilot tested at a university student foodservice center. The technological platform in this test collected data every six minutes over a 24 hour period, across two primary domains: time and temperatures within freezers, walk-in refrigerators and dry storage areas. The results of this pilot study briefly illustrated how technology can assist in food safety surveillance and monitoring by efficiently detecting food safety abnormalities related to time and temperatures so that efficient and proper response in “real time” can be addressed to prevent potential foodborne illnesses.     

Foodborne Illness,Australia, Circa 2000 and Circa 2010

Foodborne disease is a major public health problem worldwide. To examine changes in foodborne illness in Australia, we estimated the incidence, hospitalizations, and deaths attributed to contaminated food circa 2010 and recalculated estimates from circa 2000. Approximately 25% of gastroenteritis cases were caused by contaminated food; to account for uncertainty we used simulation techniques to estimate 90% credible intervals. We estimate that circa 2010, 4.1 million foodborne gastroenteritis cases occurred, and circa 2000, 4.3 million cases occurred. Circa 2010, contaminated food was estimated to be responsible for 30,840 gastroenteritis-associated hospitalizations, 76 associated deaths, and 5,140 nongastrointestinal illnesses. Cases of salmonellosis and campylobacteriosis increased from 2000 to 2010 and were the leading causes of gastroenteritis-associated hospitalizations; Listeria monocytogenes and nontyphoidal Salmonella spp. infections were the leading causes of death. Although the overall incidence of foodborne illnesses declined over time in Australia, cases of foodborne gastroenteritis are still common.Keywords: foodborne illness, foodborne disease, gastroenteritis, epidemiology, estimate, incidence, hospitalization, death, norovirus, salmonella, campylobacter, toxin, bacteria, parasites, viruses, AustraliaFoodborne illness is a major public health problem and a common cause of illness and death worldwide. Outbreaks linked to contaminated food can affect the public’s trust and financially harm implicated businesses and associated food industries. Estimates of the effects of foodborne illnesses and individual pathogens provide evidence for policy interventions and food safety regulation. In addition, estimates of changes in the incidence of foodborne illnesses and hospitalizations over time provide information on the effectiveness of changes to food safety standards and regulation.Many agents can cause foodborne illness; some of these agents are transmitted to humans by other routes as well as by food. Most foodborne illnesses manifest as gastroenteritis, but other presentations, such as meningitis and hepatitis may also result from infection, and sequelae may occur weeks after the acute infection.Many countries have estimated the incidence of foodborne diseases (1–5). In Australia in 2000, foodborne incidence, hospitalizations, and deaths were estimated to cost 1.25 billion Australian dollars annually (6,7). However, since 2000, surveillance has substantially improved, data availability has increased, and methods have been refined. To inform current public health decisions and policies in Australia, we used new methods and datasets to estimate the incidence of infectious gastroenteritis and associated hospitalizations and deaths in Australia circa 2010. We then applied these refined methods to circa 2000 data so that estimates from the 2 periods could be directly compared.     

Risk-based estimate of effect of foodborne diseases on public health, Greece

The public health effects of illness caused by foodborne pathogens in Greece during 1996-2006 was quantified by using publicly available surveillance data, hospital statistics, and literature. Results were expressed as the incidence of different disease outcomes and as disability-adjusted life years (DALY), a health indicator combining illness and death estimates into a single metric. It has been estimated that each year ≈370,000 illnesses/million inhabitants are likely caused because of eating contaminated food; 900 of these illnesses are severe and 3 fatal, corresponding to 896 DALY/million inhabitants. Ill-defined intestinal infections accounted for the greatest part of reported cases and 27% of the DALY. Brucellosis, echinococcosis, salmonellosis, and toxoplasmosis were found to be the most common known causes of foodborne illnesses, being responsible for 70% of the DALY. Overall, the DALY metric provided a quantitative perspective on the impact of foodborne illness that may be useful for prioritizing food safety management targets.     

An analysis on current food regulations for and inspection challenges of street food: Case of Florida

This study reviews current food safety regulations of food trucks and discusses possible inspection challenges and reasons for gaps between food safety regulations and practices. To be able to assess current food regulations at the state level, the Florida Department of Health (FDOH) was selected and their current materials and documents, publicly available on the DOH website, were briefly examined. This paper highlights possible reasons for safety risks and gaps between theory and application. Food regulations, inspection challenges, mobility of trucks, vendors’ personal hygiene, undocumented illnesses, temperature violations, and unlicensed trucks can be listed as potential gaps and safety risks. Regardless of the level of strict inspection facilities offered to the vendors, there are still incomplete and unsatisfactory results displayed in the county health department (CHD) webpages as open data. This review article shows that even though the United States Department of Agriculture (USDA), the Food and Drug Administration (FDA), and local health departments control safety regulations, street food operations still face great challenges and public health issues in Florida, as well as in many states in the United States.     

Keep food safe to eat: healthful food must be safe as well as nutritious

The inclusion of food safety in the 2000 edition of the Dietary Guidelines for Americans is an important step toward ensuring their continued relevance for health promotion and disease prevention. The inclusion of food safety is consistent with the original intent of the Guidelines and the increased focus on food safety today; it also better reflects current knowledge about diet and long-term health. A wide spectrum of surveillance methods can be used to monitor progress in reducing the incidence of foodborne illness, from surveys of food safety attitudes to epidemiologic data on foodborne illness. Surveillance data show that progress is being made, but that much work remains to be done. Strategies for reducing foodborne illness require a farm-to-table approach and the involvement of all those who have a responsibility for food safety, i.e., government, industry and the public. Federal agencies and others are finding it useful to use a risk analysis framework, i.e., risk assessment, risk management and risk communication, as a means of organizing available information, identifying data gaps, quantifying risks for specific pathogens and foods, and presenting strategies for improvement. Food safety education is a critical part of the overall strategy to reduce the incidence of foodborne illness and complements regulatory, research and other activities.     

Public knowledge and attitudes regarding public health inspections of restaurants

BACKGROUND: Foodborne diseases cause 76 million illnesses in the U.S. each year, and almost half of all money spent on food is spent in restaurants. Restaurant inspections are a critical public health intervention for the prevention of foodborne disease. METHODS: A telephone survey of randomly selected Tennessee residents aged > or =18 was performed. Data were collected on respondents' demographics, knowledge, attitudes, and expectations regarding restaurant inspections. RESULTS: Of 2000 respondents, 97% were aware that restaurants are inspected regularly by the health department. More than half of the respondents believed that inspections should be performed at least 12 times per year; only one third were aware that inspections currently occur only twice per year in Tennessee. More than one third of the respondents considered an inspection score of > or =90 acceptable for a restaurant at which they would eat; the mean score in Tennessee is 82. When presented with a variety of scenarios, an overwhelming number of respondents felt that public health responses to safety violations should be far more draconian than they actually are. Survey answers did not differ consistently based on respondents' race, gender, or history of having worked in a restaurant. CONCLUSIONS: This study identified a number of public misconceptions and unrealistically high expectations of the public health restaurant-inspection system. It is important to improve consumers' understanding of inspection scores and the limitations of regulatory inspections, as well as the role of such inspections in disease prevention.     

Preliminary FoodNet data on the incidence of foodborne illnesses--selected sites,United States, 2002

In the United States, an estimated 76 million persons contract foodborne illnesses each year. CDC's Emerging Infections Program Foodborne Diseases Active Surveillance Network (FoodNet) collects data on 10 foodborne diseases in nine U.S. sites. FoodNet follows trends in foodborne infections by using laboratory-based surveillance for culture-confirmed illness caused by several enteric pathogens commonly transmitted through food. This report describes preliminary surveillance data for 2002 and compares them with 1996-2001 data. The data indicate a sustained decrease in major bacterial foodborne illnesses such as Campylobacter and Listeria, indicating progress toward meeting the national health objectives of reducing the incidence of foodborne infections by 2010 (objectives 10-1a to 10-1d). However, the data do not indicate a sustained decline in other major foodborne infections such as Escherichia coli O157 and Salmonella, indicating that increased efforts are needed to reduce further the incidence of foodborne illnesses.     

Restaurant inspection scores and foodborne disease

Restaurants in the United States are regularly inspected by health departments, but few data exist regarding the effect of restaurant inspections on food safety. We examined statewide inspection records from January 1993 through April 2000. Data were available from 167,574 restaurant inspections. From 1993 to 2000, mean scores rose steadily from 80.2 to 83.8. Mean inspection scores of individual inspectors were 69-92. None of the 12 most commonly cited violations were critical food safety hazards. Establishments scoring <60 had a mean improvement of 16 points on subsequent inspections. Mean scores of restaurants experiencing foodborne disease outbreaks did not differ from restaurants with no reported outbreaks. A variety of factors influence the uniformity of restaurant inspections. The restaurant inspection system should be examined to identify ways to ensure food safety.     

Where we are in retail food safety,how we got to where we are,and how do we get there?

Food safety has not yet been attained. This is evident from reported foodborne-disease outbreaks, laboratory-confirmed cases of diseases that can be foodborne, estimates of foodborne illness based on surveillance data, and out-of-compliance risk factors. Several activities have had an impact on food safety, but there are limitations in the way each of those activities has been or is being conducted. The activities include foodborne-disease surveillance; food sampling and testing; swabbing and testing of utensils; inspection and enforcement of regulations; use of the Food Code; on-site hazard analyses, on-site monitoring of critical control points and prompt corrective actions; applied research and challenge testing; training of public-health and food regulatory personnel; training of food workers, supervisors, and managers; and education of the public. To attain food safety, we must use common (microbiological) sense and understand the principles of transmission of foodborne-disease etiological agents and their control. A change of attitudes and program focus is necessary.     

Position of the American Dietetic Association: Food and Water Safety

It is the position of the American Dietetic Association that the public has the right to a safe food and water supply. The Association supports collaboration among food and nutrition professionals, academics, representatives of the agricultural and food industries, and appropriate government agencies to ensure the safety of the food and water supply by providing education to the public and industry, promoting technological innovation and applications, and supporting further research. New food and water safety issues evolve as the environment changes. Food and nutrition professionals should collaborate with food and agriculture industries and members of the medical community in a joint effort to address these issues. Recent food- and waterborne illnesses have occurred in new settings and/or unique foods not traditionally associated with foodborne illness outbreaks. New issues associated with food safety and security that have emerged support the need for continued education and research. Government programs have developed powerful tools such as FoodNet and PulseNet to detect food- and waterborne illness outbreaks in the United States. These government programs have provided the data to enhance public policy and educational programs such as FightBac! Mandatory and voluntary adoption of Hazard Analysis Critical Control Points in the foodservice and processing industries have contributed to a decrease in foodborne illness outbreaks from traditional foods and some microorganisms usually associated with foodborne illnesses. Food and nutrition professionals are positioned to provide food and water safety education in community, clinical settings, and foodservice operations and food industries. With an aging population and an increased number of people at risk due to medical conditions for food- and waterborne illness, food and nutrition professionals should be involved in collaborative food and water safety issues in educational, research, and policy agenda settings. As the food and nutrition experts, food and nutrition professionals must assume a major role in food and water safety education and research.     

Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--selected sites, United States, 2003

In the United States, an estimated 76 million persons contract foodborne and other acute diarrheal illnesses each year. CDC's Emerging Infections Program Foodborne Diseases Active Surveillance Network (FoodNet) collects data on diseases caused by enteric pathogens transmitted commonly through food in nine U.S. sites. FoodNet quantifies and monitors the incidence of these infections by conducting active surveillance for laboratory-diagnosed illness. This report describes preliminary surveillance data for 2003 and compares them with 1996-2002 data. The data indicate substantial declines in the incidence of infections caused by Campylobacter, Cryptosporidium parvum, Escherichia coli O157, Salmonella, and Yersinia enterocolitica. These data represent progress toward meeting the 2010 national health objectives of reducing the incidence of foodborne infections (objective nos. 10.1a, 10.1b, and 10.1d). However, increased efforts are needed to reduce further the incidence of foodborne illnesses, particularly among children.     

Application of Bayesian techniques to model the burden of human salmonellosis attributable to U.S. food commodities at the point of processing: adaptation of a Danish model

Mathematical models that estimate the proportion of foodborne illnesses attributable to food commodities at specific points in the food chain may be useful to risk managers and policy makers to formulate public health goals, prioritize interventions, and document the effectiveness of mitigations aimed at reducing illness. Using human surveillance data on laboratory-confirmed Salmonella infections from the Centers for Disease Control and Prevention and Salmonella testing data from U.S. Department of Agriculture Food Safety and Inspection Service's regulatory programs, we developed a point-of-processing foodborne illness attribution model by adapting the Hald Salmonella Bayesian source attribution model. Key model outputs include estimates of the relative proportions of domestically acquired sporadic human Salmonella infections resulting from contamination of raw meat, poultry, and egg products processed in the United States from 1998 through 2003. The current model estimates the relative contribution of chicken (48%), ground beef (28%), turkey (17%), egg products (6%), intact beef (1%), and pork (<1%) across 109 Salmonella serotypes found in food commodities at point of processing. While interpretation of the attribution estimates is constrained by data inputs, the adapted model shows promise and may serve as a basis for a common approach to attribution of human salmonellosis and food safety decision-making in more than one country.     

The impact of local environmental health capacity on foodborne illness morbidity in Maryland

Objectives. We evaluated the relationship between local food protection capacity and service provision in Maryland''s 24 local food protection programs (FPPs) and incidence of foodborne illness at the county level.Methods. We conducted regression analyses to determine the relationship between foodborne illness and local FPP characteristics. We used the Centers for Disease Control and Prevention''s FoodNet and Maryland Department of Health and Mental Hygiene outbreak data set, along with data on Maryland''s local FPP capacity (workforce size and experience levels, budget) and service provision (food service facility inspections, public notification programs).Results. Counties with higher capacity, such as larger workforce, higher budget, and greater employee experience, had fewer foodborne illnesses. Counties with better performance and county-level regulations, such as high food service facility inspection rates and requiring certified food manager programs, respectively, had lower rates of illness.Conclusions. Counties with strong local food protection capacity and services can protect the public from foodborne illness. Research on public health services can enhance our understanding of the food protection infrastructure, and the effectiveness of food protection programs in preventing foodborne illness.Protecting the food supply requires diligence from farm to fork—from ensuring that our produce is grown in sanitary conditions to inspecting restaurants to ensure that food service workers are using proper hand-washing techniques. However, foodborne outbreaks continue to dominate the media headlines. Approximately 48 million cases of foodborne illness (FBI) occur annually,¹ with 66% of foodborne outbreaks associated with restaurants and 9% with catered events.² Numerous studies demonstrate that a large percentage of outbreaks are related to poor food-handling procedures.^2,3,4 Shigella, hepatitis A, and norovirus, among many other infections, can all be readily transmitted to restaurant patrons through improper hand washing by infected food handlers.⁵ In Maryland, where restaurant sales were projected to reach $8.7 billion in 2010⁶ and nearly 55% of residents eat in sit-down restaurants on a weekly basis,⁷ 63% of foodborne outbreaks reported to the Maryland Department of Health and Mental Hygiene (DHMH) occurred in restaurants.⁸To prevent these outbreaks from occurring, a strong public health infrastructure is essential. In Maryland, ensuring that restaurants provide safe meals to consumers is the primary role of the state''s 24 county-level food protection programs (FPPs).⁹ Housed in the environmental health division of the county-level health department, these programs conduct routine inspections of restaurants (hereafter referred to as food service facilities [FSFs]), public notification programs (such as posting FSF closures in local media outlets), educational programs for both FSF workers and county residents, and collaboration with county-level legislators to develop and enforce food protection regulations, such as certified food manager programs. The ability of local FPPs to conduct these tasks and provide services is contingent on a robust infrastructure and strong internal capacity—that is, structural inputs, such as workforce size and internal budgets, that allow the FPP to deliver services such as FSF inspections.In light of new data indicating that FBI costs $156 billion a year,¹⁰ health departments are even more accountable to the public to reduce illnesses and their significant human and financial costs. With the resurgence of performance measurement at all levels of government, the need to measure local FPP capacity to protect the food supply and demonstrate the effectiveness of food protection programs, through measuring the impact of food protection programs on key public health outcomes, is more essential than ever to ensure sustained financial and political support for local programs. However, despite the longstanding importance of these food protection activities, in Maryland the relationship between county-level food protection capacity and services and FBI cases and outbreaks has not been evaluated. Using public health services and systems research methods, we sought to evaluate this relationship.     

Raw Milk Consumption among Patients with Non–Outbreak-related Enteric Infections,Minnesota, USA, 2001–2010

Raw milk has frequently been identified as the source of foodborne illness outbreaks; however, the number of illnesses ascertained as part of documented outbreaks likely represents a small proportion of the actual number of illnesses associated with this food product. Analysis of routine surveillance data involving illnesses caused by enteric pathogens that were reportable in Minnesota during 2001–2010 revealed that 3.7% of patients with sporadic, domestically acquired enteric infections had reported raw milk consumption during their exposure period. Children were disproportionately affected, and 76% of those <5 years of age were served raw milk from their own or a relative’s farm. Severe illness was noted, including hemolytic uremic syndrome among 21% of Escherichia coli O157–infected patients reporting raw milk consumption, and 1 death was reported. Raw milk consumers, potential consumers, and policy makers who might consider relaxing regulations regarding raw milk sales should be educated regarding illnesses associated with raw milk consumption.     

Surveillance for foodborne disease outbreaks--United States, 2008

Foodborne agents cause an estimated 48 million illnesses annually in the United States, including 9.4 million illnesses from known pathogens. CDC collects data on foodborne disease outbreaks submitted from all states and territories through the Foodborne Disease Outbreak Surveillance System. During 2008, the most recent year for which data are finalized, 1,034 foodborne disease outbreaks were reported, which resulted in 23,152 cases of illness, 1,276 hospitalizations, and 22 deaths. Among the 479 outbreaks with a laboratory-confirmed single etiologic agent reported, norovirus was the most common, accounting for 49% of outbreaks and 46% of illnesses. Salmonella was the second most common, accounting for 23% of outbreaks and 31% of illnesses. Among the 218 outbreaks attributed to a food vehicle with ingredients from only one of 17 defined food commodities, the top commodities to which outbreaks were attributed were poultry (15%), beef (14%), and finfish (14%), whereas the top commodities to which outbreak-related illnesses were attributed were fruits and nuts (24%), vine-stalk vegetables (23%), and beef (13%). Outbreak surveillance provides insights into the agents that cause foodborne illness, types of implicated foods, and settings where transmission occurs. Public health, regulatory, and food industry professionals can use this information to target prevention efforts against pathogens and foods that cause the most foodborne disease outbreaks.     

A qualitative exploration of the perceptions and information needs of public health inspectors responsible for food safety

Background  

In Ontario, local public health inspectors play an important frontline role in protecting the public from foodborne illness. This study was an in-depth exploration of public health inspectors' perceptions of the key food safety issues in public health, and their opinions and needs with regards to food safety information resources.     

Grade pending: the effect of the New York City restaurant sanitary grades inspection program on Salmonellosis

Journal of Public Health - New York City began public reporting of restaurant sanitary inspection grades in 2010. The policy’s impact on the incidence of foodborne illness has not been...     

The health of restaurant work: A historical and social context to the occupational health of food service

The United States currently has over one million restaurants, making food service one of the largest workforces and industry sectors in the nation's economy. Historically, concern for the health of early restaurant workers was tied largely to the hygiene of the food and thus the wellbeing of the customer rather than the individuals preparing the food. The landscape of occupational illness and injury that resulted is fraught with some of the starkest health disparities in wages, discrimination, benefits, injuries, and illness seen among US laborers. These disparities have consistently been associated with social class and economic position. Conditions identified during the early years of restaurant work, before the introduction of occupational safety and health protections, persist today largely due to tipped wages, dependence on customer discretion, and the management structure. Research and intervention efforts to control occupational health hazards should be directed toward the socioeconomic and structural roots of health problems among food service workers in the United States. Such efforts have important implications for enhancing worker protections, improving wages, and restructuring working conditions for restaurant and food service workers. They also suggest opportunities for occupational health practitioners and researchers to contribute to system-level change analysis to address centuries-old occupational health challenges still facing one of the largest sectors of workers in the country.