Differences in risk factors for transmission among Shiga toxin-producing Escherichia coli serogroups and stx profiles.

OBJECTIVES: Trends in the incidence of O157 and non-O157 serogroups of Shiga toxin-producing Escherichia coli (STEC) infections have markedly diverged. Here, we estimate the extent to which STEC serogroups share the same transmission routes and risk factors, potentially explaining these trends. METHODS: With 3048 STEC cases reported in Minnesota from 2010 to 2019, we used lasso penalized regression to estimate pooled odds ratios (pOR) for the association between STEC risk factors and specific STEC serogroups and Shiga toxin gene profiles. We used random forests as a confirmatory analysis. RESULTS: Across an extended period of time, we found evidence for person-to-person transmission associated with the O26 serogroup, relative to other serogroups (pOR = 1.32 for contact with an individual with diarrhea). Rurality was less associated with non-O157 serogroups than O157 (pOR = 1.21 for each increasing level of rurality). We also found an association between unpasteurized juice and strains carrying only stx1 (pOR = 1.41). CONCLUSIONS: Collectively, these results show differences in risk factors across STEC types, which suggest differences in the most effective routes of transmission. Serogroup-specific disease control strategies should be explored. Specifically, preventative measures for non-O157 STEC need to extend beyond those we have employed for O157 STEC.

Developing a risk management framework to improve public health outcomes by enumerating and serotyping Salmonella in ground turkey.

Salmonella enterica continues to be a leading cause of foodborne morbidity worldwide. A quantitative risk assessment model was developed to evaluate the impact of pathogen enumeration and serotyping strategies on public health after consumption of undercooked contaminated ground turkey in the USA. The risk assessment model predicted more than 20,000 human illnesses annually that would result in ~700 annual reported cases. Removing ground turkey lots contaminated with Salmonella exceeding 10 MPN/g, 1 MPN/g, and 1 MPN/25 g would decrease the mean number of illnesses by 38.2, 73.1, and 95.0%, respectively. A three-class mixed sampling plan was tested to allow the detection of positive lots above threshold levels with 2-6 (c = 1) and 3-8 samples per lot (c = 2) using 25-g and 325-g sample sizes for a 95% probability of rejecting a contaminated lot. Removal of positive lots with the presence of highly virulent serotypes would decrease the number of illnesses by 44.2-87.0%. Based on these model prediction results, risk management strategies should incorporate pathogen enumeration and/or serotyping. This would have a direct impact on illness incidence linking public health outcomes with measurable food safety objectives, at the cost of diverting production lots.

Foodborne Illness Complaint Systems Detect, and Restaurant Inspection Programs Prevent Restaurant-Associated Foodborne Illness Outbreaks.

Restaurants are important settings for foodborne illness transmission. Environmental health agencies routinely inspect restaurants to assess compliance with food safety regulations. They also evaluate foodborne illness complaints from consumers to detect potential outbreaks of foodborne illness. Local environmental health agencies were surveyed to identify methods used to conduct surveillance for consumer complaints of foodborne illness, link them to inspection grading and disclosure practices, and evaluate the association between these practices and the number of foodborne illness outbreaks in restaurant settings reported to the Centers for Disease Control and Prevention. We developed a novel framework for assessing the effectiveness of restaurant inspection grading and disclosure of inspection results while accounting for any biases introduced by surveillance factors that affect outbreak detection. Our findings showed the importance of routine restaurant inspection grading and disclosure practices as prevention measures and having a centralized database to manage consumer complaints as a useful surveillance tool for detecting outbreaks. Improving consumer complaint system structure and management can bolster outbreak detection and maximize limited public health resources while increasing the efficiency of complaint-based surveillance.

Use of Online Consumer Complaint Forms to Enhance Complaint-Based Surveillance for Foodborne Illness Outbreaks in Minnesota.

Foodborne illness complaint systems that collect consumer reports of illness following exposure at a food establishment or event are a primary tool for detecting outbreaks of foodborne illness. Approximately, 75% of outbreaks reported to the national Foodborne Disease Outbreak Surveillance System are detected through foodborne illness complaints. The Minnesota Department of Health added an online complaint form to their existing statewide foodborne illness complaint system in 2017. During 2018-2021, online complainants tended to be younger than those who used traditional telephone hotlines (mean age 39 vs 46 years; p value < 0.0001), reported illnesses sooner following onset of symptoms (mean interval 2.9 vs 4.2 days; p value = 0.003), and were more likely to still be ill at the time of the complaint (69% vs 44%; p value < 0.0001). However, online complainants were less likely to have called the suspected establishment to report their illness than those who used traditional telephone hotlines (18% vs 48%; p value < 0.0001). Of the 99 outbreaks identified by the complaint system, 67 (68%) were identified through telephone complaints alone, 20 (20%) through online complaints alone, 11 (11%) using a combination of both, and 1 (1%) through email alone. Norovirus was the most common outbreak etiology identified by both complaint system methods, accounting for 66% of outbreaks identified only via telephone complaints and 80% of outbreaks identified only via online complaints. Due to the COVID-19 pandemic in 2020, there was a 59% reduction in telephone complaint volume compared to 2019. In contrast, online complaints experienced a 25% reduction in volume. In 2021, the online method became the most popular complaint method. Although most outbreaks detected by complaints were reported by telephone complaints alone, adding an online form for complaint reporting increased the number of outbreaks detected.

Quantitative Risk Assessment of Salmonella in Ground Beef Products and the Resulting Impact of Risk Mitigation Strategies on Public Health.

Salmonellosis incidence rates have not declined over the last 15 years in the US despite a significant Salmonella prevalence reduction in meat and poultry products. Ground beef is currently regulated using only qualitative Salmonella criteria, and Salmonella enumeration values have been proposed as an alternative for implementing risk-based mitigation strategies to prevent illnesses. The purpose of this study was to develop a quantitative microbial risk assessment (QMRA) model to estimate the annual number of salmonellosis cases attributable to the consumption of ground beef contaminated with Salmonella and investigate the impact of risk management strategies on public health. Model results estimated 8,980 (6,222-14,215, 90% CI) annual illnesses attributable to ground beef consumption in the US. The removal or diversion of highly contaminated ground beef production lots containing levels above 10 MPN/g (0.4%) and 1 MPN/g (2.4%) would result in a 13.6% (5,369-12,280, 90% CI) and 36.7% (3,939-8,990, 90% CI) reduction of annual salmonellosis illnesses, respectively. Frozen ground beef cooked at home was the consumption scenario of the highest risk for acquiring salmonellosis. Highly virulent serotypes accounted for 96.7% of annual illnesses despite only being present in 13.7% of ground beef samples. The removal of MDR Salmonella would result in decreased burden of disease with a 45% reduction in acute DALY annually. Focusing salmonellosis reduction efforts on removing highly contaminated ground beef lots, highly virulent Salmonella serotypes, and MDR Salmonella from not-ready-to-eat (NRTE) products were predicted to be effective risk prevention strategies.

Quantitative risk assessment model to investigate the public health impact of varying Listeria monocytogenes allowable levels in different food commodities: A retrospective analysis.

Invasive listeriosis is a potentially fatal foodborne disease that according to this study may affect up to 32.9 % of the US population considered as increased risk and including people with underlying conditions and co-morbidities. Listeria monocytogenes has been scrutinized in research and surveillance programs worldwide in Ready-to-Eat (RTE) food commodities (RTE salads, deli meats, soft/semi-soft cheese, seafood) and frozen vegetables in the last 30 years with an estimated overall prevalence of 1.4-9.9 % worldwide (WD) and 0.5-3.8 % in the United States (US). Current L. monocytogenes control efforts have led to a prevalence reduction in the last 5 years of 4.9-62.9 % (WD) and 12.4-92.7 % (US). A quantitative risk assessment model was developed, estimating the probability of infection in the US susceptible population to be 10-10,000× higher than general population and the total number of estimated cases in the US was 1044 and 2089 cases by using the FAO/WHO and Pouillot dose-response models. Most cases were attributed to deli meats (>90 % of cases) followed by RTE salads (3.9-4.5 %), soft and semi-soft cheese and RTE seafood (0.5-1.0 %) and frozen vegetables (0.2-0.3 %). Cases attributed to the increased risk population corresponded to 96.6-98.0 % of the total cases with the highly susceptible population responsible for 46.9-80.1 % of the cases. Removing product lots with a concentration higher than 1 CFU/g reduced the prevalence of contamination by 15.7-88.3 % and number of cases by 55.9-100 %. Introducing lot-by-lot testing and defining allowable quantitative regulatory limits for low-risk RTE commodities may reduce the public health impact of L. monocytogenes and improve the availability of enumeration data.

COVID-19 vaccine confidence and reasons for vaccination among health care workers and household members.

BACKGROUND: The majority of healthcare workers (HCW) in the US report being fully vaccinated against COVID-19, yet little is known about vaccine decision-making for their household members, including children. METHODS: Cross-sectional survey July-August 2021 of HCW and their household members in Minnesota. RESULTS: 94 % of eligible participants were vaccinated with the most common reasons being wanting to protect oneself, family and loved ones. Safety concerns were the most commonly reported reasons for not being vaccinated; a significantly higher proportion of unvaccinated compared to vaccinated HCW (58 % vs 12 %, p = 0.0035) and household adults (25 % vs 5 %, p = 0.03) reported prior SARS-CoV-2 infection. Nearly half of unvaccinated adults and two-thirds of unvaccinated children would be vaccinated if a vaccine mandate were in place. CONCLUSIONS: Despite high COVID-19 vaccine acceptance among HCWs, more research is required to identify and address the needs and concerns of healthcare workers who decline COVID-19 vaccination despite availability.

SARS-CoV-2 Seroprevalence Survey in Grocery Store Workers-Minnesota, 2020-2021.

Grocery workers were essential to the workforce and exempt from lockdown requirements as per Minnesota Executive Order 20-20. The risk of COVID-19 transmission in grocery settings is not well documented. This study aimed to determine which factors influenced seropositivity among grocery workers. We conducted a cross-sectional study of Minnesota grocery workers aged 18 and older using a convenience sample. Participants were recruited using a flyer disseminated electronically via e-mail, social media, and newspaper advertising. Participants were directed to an electronic survey and were asked to self-collect capillary blood for IgG antibody testing. Data were analyzed using logistic regression and adjusted for urbanicity, which confounded the relationship between number of job responsibilities in a store and seropositivity. Of 861 Minnesota grocery workers surveyed, 706 (82%) were tested as part of this study, of which 56 (7.9%) tested positive for IgG antibodies. Participants aged 65-74 years had the highest percent positivity. Having multiple job responsibilities in a store was significantly associated with seropositivity in our adjusted model (OR: 1.14 95% CI: 1.01-1.27). Workplace factors influenced seropositivity among Minnesota grocery workers. Future research will examine other potential factors (e.g., in-store preventive measures and access to PPE) that may contribute to increased seropositivity.

Foodborne Outbreak Rates Associated with Restaurant Inspection Grading and Posting at the Point of Service: Evaluation Using National Foodborne Outbreak Surveillance Data.

ABSTRACT: A previously conducted national survey of restaurant inspection programs associated the practice of disclosing inspection results to consumers at the restaurant point of service (POS) with fewer foodborne outbreaks. We used data from the national Foodborne Disease Outbreak Surveillance System (FDOSS) to assess the reproducibility of the survey results. Programs that participated in the survey accounted for approximately 23% of the single-state foodborne illness outbreaks in restaurant settings reported to FDOSS during 2016 to 2018. Agencies that disclosed inspection results at the POS reported fewer outbreaks (mean = 0.29 outbreaks per 1,000 establishments) than those that disclosed results online (0.7) or not at all (1.0). Having any grading method for inspections was associated with fewer reported outbreaks than having no grading method. Agencies that used letter grades had the lowest numbers of outbreaks per 1,000 establishments. There was a positive association (correlation coefficient, R2 = 0.29) between the mean number of foodborne illness complaints per 1,000 establishments, per the survey, and the mean number of restaurant outbreaks reported to FDOSS (R2 = 0.29). This association was stronger for bacterial toxin-mediated outbreaks (R2 = 0.35) than for norovirus (R2 = 0.10) or Salmonella (R2 = 0.01) outbreaks. Our cross-sectional study findings are consistent with previous observations that linked the practice of posting graded inspection results at the POS with reduced occurrence of foodborne illnesses and outbreaks associated with restaurants. Support for foodborne illness surveillance programs and food regulatory activities at local health agencies is foundational for food safety systems coordinated at state and federal levels.

A Public Health Informatics Solution to Improving Food Safety in Restaurants: Putting the Missing Piece in the Puzzle.

Foodborne illnesses remain an important public health challenge in the United States causing an estimated 48 million illnesses, 128,000 hospitalizations, and 3,000 deaths per year. Restaurants are frequent settings for foodborne illness transmission. Public health surveillance - the continual, systematic collection, analysis, and interpretation of reports of health data to prevent and control illness - is a prerequisite for an effective food control system. While restaurant inspection data are routinely collected, these data are not regularly aggregated like traditional surveillance data. However, there is evidence that these data are a valuable tool for understanding foodborne illness outbreaks and threats to food safety. This article discusses the challenges and opportunities for incorporating routine restaurant inspection data as a surveillance tool for monitoring and improving foodborne illness prevention activities. The three main challenges are: 1) lack of a national framework; 2) lack of data standards and interoperability; and 3) limited access to restaurant inspection data. Tapping into the power of public health informatics represents an opportunity to address these challenges. Advancing the food safety system by improving restaurant inspection information systems and making restaurant inspection data available to support decision-making represents an opportunity to practice smarter food safety.

Confounding Role of Salmonella Serotype Dublin Testing Results of Boneless and Ground Beef Purchased for the National School Lunch Program, October 2013 to July 2017.

ABSTRACT: The Agricultural Marketing Service procures boneless and ground beef for federal nutrition assistance programs. It tests procured beef for concentrations of standard plate counts (SPCs), coliforms, and Escherichia coli and for the presence of Salmonella and Shiga toxin-producing E. coli. Any lot exceeding predefined critical limits (100,000 CFU g-1 for SPCs, 1,000 CFU g-1 for coliforms, and 500 CFU g-1 for E. coli) or positive for Salmonella or Shiga toxin-producing E. coli is rejected for purchase. Between 1 October 2013 and 31 July 2017, 166,796 boneless beef lots (each approximately 900 kg) and 25,051 ground beef sublots (each approximately 4,500 kg) were produced. Salmonella was detected in 1,955 (1.17%) boneless beef lots and 219 (0.87%) ground beef sublots. Salmonella sample size increased from an individual 25-g sample to a co-enriched 325-g sample on 1 March 2015. Salmonella presence was associated with season (lowest in spring), larger sample size, and increased log SPC in boneless and ground beef. Increased log E. coli was associated with Salmonella presence in boneless beef, but not ground beef. Salmonella Dublin was the most common serotype in boneless beef (743 of 1,407, 52.8%) and ground beef (35 of 171, 20.5%). Salmonella Dublin was generally associated with lower indicator microorganism concentrations compared with other Salmonella serotypes as a group. Relative to other Salmonella, Salmonella Dublin was associated with season (more common in spring) and smaller sample size in boneless and ground beef. Decreased log SPCs and log coliforms were associated with Salmonella Dublin presence in boneless beef, but not in ground beef. Differential associations between Salmonella Dublin and other serotypes with indicator microorganisms were strong enough to cause confounding and suggest that the presence of Salmonella Dublin needs to be accounted for when evaluating indicator performance to assess Salmonella risk in boneless and ground beef.

Can Aggregated Restaurant Inspection Data Help Us Understand Why Individual Foodborne Illness Outbreaks Occur?

ABSTRACT: Restaurant inspections seek to identify and correct risk factors for foodborne illness, but restaurant inspection data are not typically used more broadly as a food safety surveillance tool. In 2015, there was an outbreak of Salmonella serotype Newport infections associated with multiple restaurants in a chain (chain A), primarily in Minnesota. The outbreak was associated with tomatoes that were likely contaminated at the point of production. The objective of this study was to demonstrate the potential usefulness of aggregated restaurant inspection data in aiding individual outbreak investigations. Reports of the last inspection for all chain A restaurants that preceded the first reported case meal date in the outbreak were obtained from local health departments and the Minnesota Department of Health. Ordinal logistic regression was used to assess differences in risk factor and good retail practice violation categories and specific violations in restaurants with zero cases (nonoutbreak restaurants) (n = 25), one to two cases (n = 16), and at least three cases (n = 13). For restaurants with a "protection from contamination" violation in the routine inspection that preceded the outbreak, the proportional odds ratio for outbreak level was 4.92 (95% confidence interval: 1.57, 15.39; P = 0.01). These findings suggest that food handling practices in the outbreak restaurants may have increased contamination of foods through cross-contamination, which in turn increased transmission at outbreak restaurants. These data suggest that aggregated data from routine inspection reports can provide useful information to aid in outbreak investigations and other foodborne illness surveillance and prevention activities.

Consumer Interest and Preferred Formats for Disclosure of Restaurant Inspection Results, Minnesota 2019.

ABSTRACT: In recent years, numerous state and local health departments have developed systems to disclose restaurant inspection results to consumers. Public disclosure of restaurant inspection results can reduce transmission of foodborne illness by driving improvements in sanitary conditions. In Minnesota, restaurant inspection results are not readily accessible for consumers to use to make decisions about where to eat. The objective of this study was to assess the consumer interest among Minnesota adults in having better access to restaurant inspection results and to identify preferred formats for disseminating this information. We conducted a survey among 1,188 Minnesota residents aged 18 years or older at the 2019 Minnesota State Fair. Overall, 94.4% of respondents wanted better access to restaurants' inspection information. More than three-quarters (77.1%) of respondents stated that they would use this information to decide where to eat. Respondents wanted to see inspection results online (71.6%) and at restaurants (62.1%). Increasing public access to inspection results could reinforce efforts by public health agencies and food service operators to improve the safety of foods prepared away from home.

Microbiological Testing Results of Boneless and Ground Beef Purchased for the U.S. National School Lunch Program, School Years 2015 to 2018.

The Agricultural Marketing Service (AMS) purchases beef for the National School Lunch Program and other federal nutrition assistance programs. For beef that will be delivered to food service facilities raw, each ca. 900-kg lot of boneless beef raw material and each ca. 4,500-kg sublot of resultant ground beef is tested for standard plate count (SPC) organisms, coliforms, Escherichia coli, Salmonella, and E. coli O157:H7. In addition, 1 of every 10 lots of boneless beef, randomly selected, is tested for E. coli O26, O45, O103, O111, O121, and O145. For beef that will be cooked using a validated lethality step at a federally inspected establishment before delivery, each lot of boneless beef and each sublot of ground beef is tested for SPC organisms, coliforms, and E. coli only. Any lot or sublot exceeding predefined critical limits (CLs) of 100,000 CFU g-1 for SPC organisms, 1,000 CFU g-1 for coliforms, or 500 CFU g-1 for E. coli or for beef containing Salmonella or any of previously mentioned E. coli serotypes is rejected for purchase. For school years 2015 through 2018 (July 2014 through June 2018), 220,497,254 kg of boneless beef and 189,347,318 kg of ground beef were produced for AMS. For boneless beef, 133 (0.06%), 164 (0.07%), and 106 (0.04%) of 240,488 lots exceeded CLs for SPC organisms, coliforms, and E. coli, respectively; 2,038 (1.30%) and 116 (0.07%) of 156,671 lots were positive for Salmonella and E. coli O157:H7, respectively; and 59 (0.36%) of 16,515 lots were positive for non-O157 Shiga toxin-producing E. coli. For ground beef, 46 (0.10%), 27 (0.06%), and 19 (0.04%) of 45,769 sublots exceeded CLs for SPC organisms, coliforms, and E. coli, respectively; and 329 (1.40%) and 18 (0.08%) of 23,475 sublots were positive for Salmonella and E. coli O157:H7, respectively. All lots and sublots found to exceed indicator organism CLs or to contain pathogens were identified, rejected for purchase, and diverted from federal nutrition assistance programs.

Prioritization of Chicken Meat Processing Interventions on the Basis of Reducing the Salmonella Residual Relative Risk.

Protecting public health by controlling Salmonella in chicken meat products continues to be a challenge to both industry and policymakers. Studies evaluating the combined use of commercially available antimicrobial interventions are scarce. The aim of this work was to develop a risk-based prioritization framework to rank chicken meat processing interventions that achieve the greatest Salmonella relative risk reduction. A baseline model characterizing the current U.S. broiler industry food safety intervention practices was created from direct observation of processes and expert elicitation. Results showed the combination of chlorine at the bird wash station and peroxyacetic acid at the on-line reprocessing and chill stages as the most common U.S. processing scenario. Irradiation at packaging and acidified sodium chlorite at evisceration were the most effective single processing interventions (98.8 and 91.6% risk reduction, respectively); however, no single intervention was able to comply with the current Food Safety and Inspection Service Salmonella postchill performance standards. The combination of peroxyacetic acid in at least one of the chicken processing stages with the current set of U.S. baseline interventions achieved >99% Salmonella relative risk reduction and ensured Food Safety and Inspection Service compliance. Adding more than one intervention to the U.S. current practice did not enhance (<2%) the overall Salmonella risk reduction. This study can help poultry processors to prioritize food safety interventions to maximize Salmonella reduction and public health protection.

Moving Away from Population-Based Case-Control Studies during Outbreak Investigations.

Population-based case-control studies are a time- and labor-intensive component of foodborne outbreak investigations. One alternative is a binomial trial that asks the question "if the likelihood of each case's having eaten a given food is no different from that of the average person in the population, how often would we find, by chance alone, that x of n (or more) cases would have eaten this food?" Calculating a binomial trial requires background exposure data. We conducted case-control studies and binomial trials in two foodborne outbreaks and compared results. In both outbreaks, using binomial trials we found much less than a 5% probability that the number of cases eating the suspected food vehicle would have occurred by chance. These results were comparable with results of the case-control studies, but with considerably less effort. When background exposure data are available, binomial trials are an efficient way to explore hypotheses that can be further tested by traceback efforts to identify a common source.

Understanding the Relation between Establishment Food Safety Management and Salmonella Risk Factor Violations Cited during Routine Inspections.

Restaurants are a frequent setting for outbreaks and sporadic cases of Salmonella. The relationship among food safety management characteristics, compliance with procedures to reduce Salmonella-associated risk factors (as found during routine inspections), and the likelihood that an establishment has experienced a sporadic Salmonella case was assessed. Individual risk factor violations associated with Salmonella transmission pathways were identified by a literature review. Data from 546 routine inspection reports collected from July 2016 to June 2017, including 25 from restaurants that had experienced a sporadic case of Salmonella, were evaluated. In restaurants with certified food managers, there were fewer observations of Salmonella risk factor reduction procedures that were not in compliance. For establishments that had experienced sporadic cases of Salmonella, the person in charge at the time of an inspection was less likely to have been the establishment's official certified food manager of record (rate ratio = 0.4, 95% confidence interval = 0.2 to 0.8; P = 0.01), and there was increased likelihood of being found out of compliance for prevention of contamination by hands (rate ratio = 3.7, 95% confidence interval = 1.4 to 8.1; P = 0.001). The results of this study warrant future research on the dynamics of food safety management systems, the effect they have on risk factor violations cited on routine inspection results, and the risk for transmission of Salmonella. Analyzing routine inspection data as hazard surveillance may be useful to identify food establishments at a greater risk for transmitting Salmonella infections.

Risk Factor Violations Associated With Sporadic Salmonella Cases.

FDA promotes assessment of routine restaurant inspection programs to measure trends in the occurrence of risk factors and compare data with national benchmarks. Reductions in the occurrence of risk factors should be accompanied by reductions in the occurrence of foodborne illnesses. The objectives of this study were to: (1) assess changes in risk factor violations in Bloomington restaurants between 2010 and 2015, in order to (2) compare patterns of risk factor violations in Bloomington restaurants that served sporadic Salmonella cases from 2010 to 2015 to these observed trends. FDA-based risk factor surveys were conducted in 2010 and 2015. Food contact surfaces were most frequently cited as out-of-compliance in both years. The proportion of inspections with employee health policy violations were reduced from 2010 to 2015, reflecting inspection priorities that were established after the 2010 survey. From 2010 to 2015, 154 sporadic Salmonella case exposures were reported from Bloomington restaurants. Food contact surfaces (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 1.6, 3.5) and handwash facilities stocked (OR = 2.7; 95% CI = 1.7, 4.0) were more frequently found out-of-compliance in inspections that served sporadic Salmonella cases, in both individual year comparisons and in the overall comparison. The finding that violations such as food contact surfaces not being clean to sight and touch or sanitized before use and handwash facilities not being stocked with hand cleanser, sanitary towels, or hand drying devices, were more likely to be cited in sporadic Salmonella cases than during the FDA-based risk factor survey, suggests that these may contribute to an increased risk of Salmonella transmission in restaurants. Because restaurant inspections represent routine public health activities that are conducted by a broad range of agencies, establishing methods to analyze the results of these inspections across agencies and over time may help us better understand how risk factors cited on routine inspections can predict the likelihood a food establishment will be implicated in a foodborne illness case, in both sporadic cases and outbreaks.

Restaurant Inspection Letter Grades and Salmonella Infections, New York, New York, USA.

Rates of Salmonella infection in the United States have not changed over the past 20 years. Restaurants are frequent settings for Salmonella outbreaks and sporadic infections. Few studies have examined the effect of posting letter grades for restaurant inspections on the incidence of foodborne illness. We compared Salmonella infection rates in New York, New York, USA (NYC), with those in the rest of New York state before and after implementation of a letter grade system for restaurant inspections in NYC. We calculated a segmented regression model for interrupted time series data. After implementation of letter grading, the rate of Salmonella infections decreased 5.3% per year in NYC versus the rest of New York state during 2011-2015, compared with the period before implementation, 2006-2010. Posting restaurant inspection results as letter grades at the point of service was associated with a decline in Salmonella infections in NYC and warrants consideration for broader use.

Understanding the Relation between Establishment Food Safety Management and Risk Factor Violations Cited during Routine Inspections.

Certified Food Manager (CFM) training can help ensure proper food safety practices for decreasing risk factor violations associated with foodborne illness. However, the effectiveness of food safety management also depends on the authority of the person in charge (PIC) and the added value of third-party inspectors auditing food safety policies and practices. To examine the effect of food safety management characteristics on risk factor violations cited on routine inspections, we evaluated results of 546 routine inspections in the cities of Bloomington and Richfield, MN, between 2016 and 2017. Food establishment management was characterized by the presence of a CFM of record for the establishment, whether the PIC was certified, and whether the establishment used a third-party inspector to audit food safety policies and practices. For each of these food safety management characteristics, the establishment had fewer risk factor observations that were out of compliance during routine inspections. The relationship between the establishment's food safety management characteristics and either the percentage of observations out of compliance or the inspections with observations out of compliance differed by risk factor category. For preventing contamination by hands, the lowest rates were found for inspections in which the CFM of record was the PIC. However, for potentially hazardous food time and temperature violations, establishments that used third-party inspectors had lower percentages of both observations and inspections out of compliance across all categories of management characteristics. The results of our study support the recommendations of the U.S. Food and Drug Administration regarding CFMs. However, our findings also suggest greater complexity in the characteristics of food safety management, which include the role of third-party inspectors and whether a CFM is acting in the role of the CFM of record.