Restaurant and Staff Characteristics Related to Practices that Could Contribute to Cross-Contamination.

Foodborne illness is a persistent public health concern in the U.S.; over 800 foodborne illness outbreaks are reported to the Centers for Disease Control and Prevention (CDC) annually. Most of these outbreaks (60%) are linked with restaurants. Contamination of food with foodborne pathogens during preparation and storage is a significant contributing factor to many of these outbreaks. The CDC's Environmental Health Specialists Network (EHS-Net) collected data to identify restaurant characteristics, policies, and practices associated with contamination prevention practices. Data collectors interviewed managers and conducted kitchen observations in 312 restaurants across six EHS-Net sites in five states. Data collectors observed at least one food worker action that could lead to contamination in 63.1% of restaurants. The most frequently observed action that could lead to contamination was bare-hand or dirty glove contact with ready-to-eat food (35.9%). The estimated mean number of observed potential contamination actions was greater in restaurants that were independently owned (does not share a name and operations with other restaurants), did not require managers to be certified in food safety, did not have workers trained in food safety, did not have a handwashing policy, did not have a policy minimizing bare-hand contact with ready-to-eat foods, and had a manager with more than two years of experience at their current restaurant. These results suggest that to improve contamination prevention, the foodservice industry and food safety officials can consider supporting and encouraging strong food safety training and policies, particularly concerning hand hygiene, and targeting interventions to independent restaurants.

Evaluation of Data Sources for Carbon Monoxide Poisoning Surveillance in New York City.

CONTEXT: Carbon monoxide (CO) exposure can be life-threatening. Suspected and confirmed cases of CO poisoning warranting health care in New York City (NYC) are reportable to the NYC Poison Control Center (PCC). OBJECTIVES: We evaluated 4 hospital-based sources of CO surveillance data to identify ways to improve data capture and reporting. DESIGN: Suspected and confirmed CO poisoning records from October 2015 through December 2016 were collected from the NYC emergency department (ED) syndromic surveillance system, New York State Statewide Planning and Research Cooperative System (SPARCS) ED billing data, NYC PCC calls made from hospitals, and the Electronic Clinical Laboratory Reporting System (ECLRS). Syndromic and SPARCS records were person- and visit-matched. SPARCS and ECLRS records were also matched to PCC records on combinations of name, demographic characteristics, and visit information. SETTING: Hospitals in NYC. PARTICIPANTS: Individuals who visited NYC hospitals for CO-related health effects. MAIN OUTCOME MEASURES: We assessed the validity of syndromic data, with SPARCS records as the gold standard. We matched SPARCS and ECLRS records to PCC records to analyze reporting rates by case characteristics. RESULTS: The sensitivity of syndromic surveillance was 60% (225 true-positives detected among 372 visit-matched SPARCS cases), and positive predictive value was 46%. Syndromic records often missed CO flags because of a nonspecific or absent International Classification of Diseases code in the diagnosis field. Only 15% of 428 SPARCS records (total includes 56 records not visit-matched to syndromic) and 16% of 199 ECLRS records were reported to PCC, with male sex and younger age associated with higher reporting. CONCLUSIONS: Mandatory reporting makes PCC useful for tracking CO poisoning in NYC, but incomplete reporting and challenges in distinguishing between confirmed and suspected cases limit its utility. Simultaneous tracking of the systems we evaluated can best reveal surveillance patterns.

Observed Potential Cross-Contamination in Retail Delicatessens.

ABSTRACT: Listeria monocytogenes is a persistent public health concern in the United States and is the third leading cause of death from foodborne illness. Cross-contamination of L. monocytogenes (between contaminated and uncontaminated equipment, food, and hands) is common in delicatessens and likely plays a role in the foodborne illness associated with retail deli meats. In 2012, the Centers for Disease Control and Prevention's Environmental Health Specialists Network conducted a study to describe deli characteristics related to cross-contamination with L. monocytogenes. The study included 298 retail delis in six state and local health departments' jurisdictions and assessed how well deli practices complied with the U.S. Food and Drug Administration Food Code provisions. Among delis observed using wet wiping cloths for cleaning, 23.6% did not store the cloths in a sanitizing solution between uses. Observed potential cross-contamination of raw meats and ready-to-eat foods during preparation (e.g., same knife used on raw meats and ready-to-eat foods, without cleaning in between) was present in 9.4% of delis. In 24.6% of delis with a cold storage unit, raw meats were not stored separately from ready-to-eat products in containers, bins, or trays. A proper food safety management plan can reduce gaps in cross-contamination prevention and should include adopting procedures to minimize food safety risks, instituting training with instruction and in-person demonstrations and certifying staff on those procedures, and monitoring to ensure the procedures are followed.

Cardiovascular Health Risk Behaviors by Occupation in the NYC Labor Force.

OBJECTIVE: We explored associations between occupation and cardiovascular disease (CVD) risk behaviors including: attempted weight loss, physical activity, smoking, and restaurant meal and sugary beverage consumption. METHODS: We used NYC Health and Nutrition Examination Survey 2013 to 2014 data, and coded free-text, occupational question responses using 2010 US Census Bureau Classification. CVD risk behaviors were compared across occupational categories, using regression to adjust for demographics. RESULTS: There were health behavior differences across occupational categories. Construction/transportation/maintenance workers smoked more and were less likely than management to attempt weight loss, service workers were less likely to eat restaurant-prepared meals, sales/office workers were less likely to be physically active (all P < 0.05). Adjusting for demographics, differences in health behaviors were reduced, but remained present. CONCLUSIONS: Knowledge of occupational disparities may aid chronic disease prevention by identifying populations for targeted interventions.

Retail Deli Characteristics Associated with Sanitizing Solution Concentrations.

ABSTRACT: Listeria monocytogenes is commonly found in retail delicatessen environments. Proper types and concentrations of sanitizers must be used to eliminate this pathogen from surfaces and reduce the consumer's risk for infection. In 2012, the Environmental Health Specialists Network of the Centers for Disease Control and Prevention completed a study on practices in retail delis that can help prevent cross-contamination and growth of L. monocytogenes. The present study focuses on the sanitizing solution used in delis, given its importance to cleaning and reducing pathogen contamination in retail food environments. We identified deli, manager, and worker characteristics associated with use of improper concentrations of sanitizing solution to wipe down food contact surfaces; 22.8% of sanitizing solutions used for wiping food contact surfaces were at improper concentrations. Independent delis were more likely to use improper concentrations of sanitizing solution, as were delis that sold fewer chubs (plastic tubes of meat) per week. Use of improper sanitizing solution concentrations was associated with required food safety training for managers; additional analyses suggest that this relationship is significant for independent but not chain delis. Cleaning and sanitizing must be emphasized in food safety efforts focused on independent and smaller delis.

Impact of a Municipal Policy Restricting Trans Fatty Acid Use in New York City Restaurants on Serum Trans Fatty Acid Levels in Adults.

OBJECTIVES: To estimate the impact of the 2006 policy restricting use of trans fatty acids (TFAs) in New York City restaurants on change in serum TFA concentrations in New York City adults. METHODS: Two cross-sectional population-based New York City Health and Nutrition Examination Surveys conducted in 2004 (n = 212) and 2013-2014 (n = 247) provided estimates of serum TFA exposure and average frequency of weekly restaurant meals. We estimated the geometric mean of the sum of serum TFAs by year and restaurant meal frequency by using linear regression. RESULTS: Among those who ate less than 1 restaurant meal per week, geometric mean of the sum of serum TFAs declined 51.1% (95% confidence interval [CI] = 42.7, 58.3)-from 44.6 (95% CI = 39.7, 50.1) to 21.8 (95% CI = 19.3, 24.5) micromoles per liter. The decline in the geometric mean was greater (P for interaction = .04) among those who ate 4 or more restaurant meals per week: 61.6% (95% CI = 55.8, 66.7) or from 54.6 (95% CI = 49.3, 60.5) to 21.0 (95% CI = 18.9, 23.3) micromoles per liter. CONCLUSIONS: New York City adult serum TFA concentrations declined between 2004 and 2014. The indication of greater decline in serum TFAs among those eating restaurant meals more frequently suggests that the municipal restriction on TFA use was effective in reducing TFA exposure. Public Health Implications. Local policies focused on restaurants can promote nutritional improvements.

Tracking Declines in Mercury Exposure in the New York City Adult Population, 2004-2014.

Mercury is a toxic metal that can be measured in human blood and urine. Population-based biomonitoring from 2004 guided New York City (NYC) Department of Health and Mental Hygiene (DOHMH) efforts to reduce exposures by educating the public about risks and benefits of fish consumption-a predominant source of exposure in the general population-and removing mercury-containing skin-lightening creams and other consumer products from the marketplace. We describe changes in exposures over the past decade in relation to these local public health actions and in the context of national changes by comparing mercury concentrations measured in blood (1201 specimens) and urine (1408 specimens) from the NYC Health and Nutrition Examination Survey (NYC HANES) 2013-2014 with measurements from NYC HANES 2004 and National Health and Nutrition Examination Surveys (NHANES) 2003-2004 and 2013-2014. We found that NYC adult blood and urine geometric mean mercury concentrations decreased 46% and 45%, respectively. Adult New Yorkers with blood mercury concentration ≥ 5 µg/L (the New York State reportable level) declined from 24.8% (95% CL = 22.2%, 27.7%) to 12.0% (95% CL = 10.1%, 14.3%). The decline in blood mercury in NYC was greater than the national decline, while the decline in urine mercury was similar. As in 2004, Asian New Yorkers had higher blood mercury concentrations than other racial/ethnic groups. Foreign-born adults of East or Southeast Asian origin had the highest prevalence of reportable levels (29.7%; 95% CL = 21.0%, 40.1%) across sociodemographic groups, and Asians generally were the most frequent fish consumers, eating on average 11 fish meals in the past month compared with 7 among other groups (p < 0.001). Fish consumption patterns were similar over time, and fish continues to be consumed more frequently in NYC than nationwide (24.7% of NYC adults ate fish ten or more times in the past 30 days vs. 14.7% nationally, p < 0.001). The findings are consistent with the hypothesis that blood mercury levels have declined in part because of local and national efforts to promote consumption of lower mercury fish. Local NYC efforts may have accelerated the reduction in exposure. Having "silver-colored fillings" on five or more teeth was associated with the highest 95th percentile for urine mercury (4.06 µg/L; 95% CL = 3.1, 5.9). An estimated 5.5% of the adult population (95% CL = 4.3%, 7.0%) reported using a skin-lightening cream in the past 30 days, but there was little evidence that use was associated with elevated urine mercury in 2013-14.

Hot Weather Impacts on New York City Restaurant Food Safety Violations and Operations.

Previous studies have shown that higher ambient air temperature is associated with increased incidence of gastrointestinal illnesses, possibly as a result of leaving potentially hazardous food in the temperature danger zone for too long. However, little is known about the effect of hot weather on restaurant practices to maintain safe food temperatures. We examined hot weather impacts on restaurant food safety violations and operations in New York City using quantitative and qualitative methods. We used data from 64,661 inspections conducted among 29,614 restaurants during May to September, 2011 to 2015. We used Poisson time-series regression to estimate the cumulative relative risk (CRR) of temperature-related food safety violations across a range of daily maximum temperature (13 to 40°C [56 to 104°F]) over a lag of 0 to 3 days. We present CRRs for an increase in daily maximum temperature from the median (28°C [82°F]) to the 95th percentile (34°C [93°F]) values. Maximum temperature increased the risk of violations for cold food holding above 5°C (41°F) (CRR, 1.19; 95% CI, 1.14, 1.25) and insufficient refrigerated or hot holding equipment (CRR, 2.37; 95% CI, 2.02, 2.79). We also conducted focus groups among restaurant owners and managers to aid interpretation of findings and identify challenges or knowledge gaps that prevent hot weather preparedness. Focus group participants cited refrigeration issues as a common problem during hot weather. Participants expressed the need for more guidance on hot weather and power outages to be delivered concisely. Our findings suggest that hotter temperatures may compromise cold and hot food holding, possibly by straining refrigeration or other equipment. The findings have public health implications because holding potentially hazardous foods in the temperature danger zone allows foodborne pathogens to proliferate and increases risk for foodborne illness. Distribution of simple guidelines that can be easily accessed during emergencies could help restaurants respond better.

Declines in adult blood lead levels in New York City compared with the United States, 2004-2014.

OBJECTIVES: To assess changes in lead exposure in the New York City (NYC) adult population over a 10-year period and to contrast changes with national estimates, overall, and by socio-demographics and smoking status. METHODS: We used measurements of blood lead levels (BLLs) from NYC resident adults who participated in the NYC Health and Nutrition Examination Surveys (HANES) in 2004 and 2013-2014. We compared estimates of geometric means (GM), 95th percentiles, and prevalence of BLL ≥ 5 µg/dL overall and by subgroups over time, with adults who participated in the National HANES (NHANES) 2001-2004 and 2011-2014. RESULTS: The GM BLLs among NYC adults declined from 1.79 µg/dL in 2004 to 1.13 µg/dL in 2013-2014 (P < .0001). The declines over this period ranged from 30.1% to 43.2% across socio-demographic groups and smoking status (P < .0001 for all comparisons), and were slightly greater than declines observed nationally. The drop in prevalence of elevated BLLs (≥ 5 µg/dL) was also greater in NYC (4.8-0.5%), compared with NHANES (3.8-2.0%). By 2013-2014, NYC adults with lower annual family income (< $20,000) no longer had higher GM BLLs relative to those with higher incomes (≥ $75,000), a disparity improvement not observed nationally. Likewise, GM BLLs and 95th percentiles for non-Hispanic black adults in NYC were lower than GM BLLs for non-Hispanic white adults. Non-Hispanic Asian adults had the highest GM BLLs compared with other racial/ethnic groups, both in NYC in 2013-14 and nationally in 2011-2014 (1.37 µg/dL, P = .1048 and 1.22 µg/dL, P = .0004, respectively). CONCLUSION: The lessening of disparity in lead exposure across income groups and decreasing exposure at the high end of the distribution among non-Hispanic black and Asian adults in NYC suggest that regulatory and outreach efforts have effectively targeted these higher exposure risk groups. However, Asian adults still had the highest average BLL, suggesting a need for enhanced outreach to this group. Local surveillance remains an important tool to monitor BLLs of local populations and to inform initiatives to reduce exposures in those at highest risk.

Using Tracking Data to Promote Environmental Public Health Through Regulatory and Legislative Processes in New York City.

Legislation and regulation are powerful tools for decreasing health risks from environmental hazards. Legislation is enacted by an elected body, and regulations are issued by an agency in the executive branch delegated authority by the legislature to carry out enacted laws. The New York City (NYC) Environmental Public Health Tracking Program makes data and analytic findings available to policy makers to inform development of sound and effective environmental health legislation and regulation. Tracking data and associated science create awareness of environmental hazards and health impacts, guide strategies for mitigating hazards, and sustain support for effective law by documenting beneficial impacts on the environment and health. We describe how environmental and health surveillance data and analytic findings have informed legislation and regulations related to restaurant food safety and air pollution control in NYC. Using data to guide legislative and regulatory processes helps ensure that policy decisions and directions are based on objective evidence.

Using tracking infrastructure to support public health programs, policies, and emergency response in New York City.

OBJECTIVE: To describe how the New York City (NYC) Tracking Program has used nationally mandated Secure Portal infrastructure and staff analytical expertise to support programs and inform policy. SETTING: The NYC Health Department assesses, investigates, and acts on a wide range of environmental concerns to protect the health of New Yorkers. DESIGN: Specific examples of highly effective policies or initiatives that relied on the NYC Tracking Program are described, including restaurant sanitary grade posting, rat indexing, converting boilers to cleaner-burning fuels, reducing exposure to mercury from fish and contaminated products, and responding to Superstorm Sandy. CONCLUSIONS: The NYC Tracking Program supports the Health Department in using inspectional, administrative, and health data to guide operations. Tracking has also allowed internal and external partners to use these data to guide policy development.

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.

Population-based biomonitoring of exposure to organophosphate and pyrethroid pesticides in New York City.

BACKGROUND: Organophosphates and pyrethroids are the most common classes of insecticides used in the United States. Widespread use of these compounds to control building infestations in New York City (NYC) may have caused higher exposure than in less-urban settings. OBJECTIVES: The objectives of our study were to estimate pesticide exposure reference values for NYC and identify demographic and behavioral characteristics that predict exposures. METHODS: The NYC Health and Nutrition Examination Survey was a population-based, cross-sectional study conducted in 2004 among adults ≥ 20 years of age. It measured urinary concentrations of organophosphate metabolites [dimethylphosphate (DMP), dimethylthiophosphate (DMTP), dimethyldithiophosphate, diethylphosphate, diethylthiophosphate, and diethyldithiophosphate] in 883 participants, and pyrethroid metabolites [3-phenoxybenzoic acid (3-PBA), trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid (trans-DCCA), 4-fluoro-3-phenoxybenzoic acid, and cis-3-(2,2-dibromovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid] in 1,452 participants. We used multivariable linear regression to estimate least-squares geometric mean total dialkylphospate (ΣDAP) and 3-PBA concentrations across categories of predictors. RESULTS: The dimethyl organophosphate metabolites had the highest 95th percentile concentrations (87.4 µg/L and 74.7 µg/L for DMP and DMTP, respectively). The highest 95th percentiles among pyrethroid metabolites were measured for 3-PBA and trans-DCCA (5.23 µg/L and 5.94 µg/L, respectively). Concentrations of ΣDAP increased with increasing age, non-Hispanic white or black compared with Hispanic race/ethnicity, professional pesticide use, and increasing frequency of fruit consumption; they decreased with non-green vegetable consumption. Absolute differences in geometric mean urinary 3-PBA concentrations across categories of predictors were too small to be meaningful. CONCLUSION: Estimates of exposure to pyrethroids and dimethyl organophosphates were higher in NYC than in the United States overall, underscoring the importance of considering pest and pesticide burdens in cities when formulating pesticide use regulations.

Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City.

BACKGROUND: Mercury is a toxic metal that has been used for centuries as a constituent of medicines and other items. OBJECTIVE: We assessed exposure to inorganic mercury in the adult population of New York City (NYC). METHODS: We measured mercury concentrations in spot urine specimens from a representative sample of 1,840 adult New Yorkers in the 2004 NYC Health and Nutrition Examination Survey. Cases with urine concentrations ≥ 20 µg/L were followed up with a telephone or in-person interview that asked about potential sources of exposure, including ritualistic/cultural practices, skin care products, mercury spills, herbal medicine products, and fish. RESULTS: Geometric mean urine mercury concentration in NYC was higher for Caribbean-born blacks [1.39 µg/L; 95% confidence interval (CI), 1.14-1.70] and Dominicans (1.04 µg/L; 95% CI, 0.82-1.33) than for non-Hispanic whites (0.67 µg/L; 95% CI, 0.60-0.75) or other racial/ethnic groups. It was also higher among those who reported at least 20 fish meals in the past 30 days (1.02 µg/L; 95% CI, 0.83-1.25) than among those who reported no fish meals (0.50 µg/L; 95% CI, 0.41-0.61). We observed the highest 95th percentile of exposure (21.18 µg/L; 95% CI, 7.25-51.29) among Dominican women. Mercury-containing skin-lightening creams were a source of exposure among those most highly exposed, and we subsequently identified 12 imported products containing illegal levels of mercury in NYC stores. CONCLUSION: Population-based biomonitoring identified a previously unrecognized source of exposure to inorganic mercury among NYC residents. In response, the NYC Health Department embargoed products and notified store owners and the public that skin-lightening creams and other skin care products that contain mercury are dangerous and illegal. Although exposure to inorganic mercury is not a widespread problem in NYC, users of these products may be at risk of health effects from exposure.

Characterization of residential pest control products used in inner city communities in New York City.

The Columbia Center for Children's Environmental Health (CCCEH) previously reported widespread residential insecticide use in urban communities in New York City. Research suggests that pyrethroids are replacing organophosphates (OPs) in response to 2000-2001 US EPA pesticide regulations restricting OP use. A systematic assessment of active ingredients used for residential pest control is lacking. We queried a database of pesticide applications reported by licensed applicators between 1999 and 2005 and surveyed pest control products available in 145 stores within 29 zip codes in the CCCEH catchment area including Northern Manhattan and the South Bronx. Pyrethroids, pyrethrins, piperonyl butoxide, and hydramethylnon were the most common insecticide active ingredients reported as used by licensed pesticide applicators within the 29 zip codes of the CCCEH catchment area between 1999 and 2005. Use of certain pyrethroids and some non-spray insecticides such as fipronil and boric acid increased significantly by year (logistic regression, OR>1.0, P<0.05), whereas use of OPs, including chlorpyrifos and diazinon decreased significantly by year (logistic regression, OR<1.0, P<0.05). Among pesticide applicators, the most commonly applied active ingredients were formulated as spray applications. With 145 stores in the catchment area, 120 (82.5%) carried at least one insecticide. Spray cans were most common (114/120 stores, 95%); gels were least common (31/120 stores, 25.8%). Among spray formulations, pyrethroid insecticides were the most common pesticide class and permethrin, a pyrethroid, was the most common individual active ingredient. In 2007, one store carried a product containing chlorpyrifos and one store carried a product containing diazinon. This survey suggests that certain pyrethroids and non-spray insecticides replaced OPs for pest control in this area. Chlorpyrifos and diazinon have nearly been eliminated from products marketed for residential pest control.

Erratum: "A Biomonitoring Study of Lead, Cadmium, and Mercury in the Blood of New York City Adults".

[This corrects the article DOI: 10.1289/ehp.10056.].

Mercury and polychlorinated biphenyls in Asian market fish: a response to results from mercury biomonitoring in New York City.

In 2004, the New York City (NYC) Health and Nutrition Examination Survey measured the highest blood mercury levels in Asian and foreign-born Chinese demographic groups. Fish consumption was the strongest predictor of exposure. The survey did not inquire about consumption of individual species, and subsequent visits to fish markets serving the Asian community suggested that many popular species lack contaminant data. Our objective was to supplement existing information on contaminants in commercial fish by collecting data on species present in markets serving the Asian community. We measured total mercury and the sum of 101 polychlorinated biphenyl (PCB) congeners in 282 individual specimens of 19 species or products from retail fish markets in Chinese neighborhoods in NYC. Species were selected based on their volume in the market, and an absence or insufficiency of national data on mercury levels. PCBs were measured because they are also contaminants of concern. All measurements were made on a wet weight basis on whole fillets (with skin) or products (drained of liquid). Mean mercury levels ranged from below the limit of detection (0.004microg/g) in tilapia to 0.229microg/g in tilefish. The highest mercury level (1.150microg/g) was measured in a tilefish specimen, and mercury levels in tilefish increased with the specimen size. Mean PCB levels ranged from 1ng/g in red snapper to 98ng/g in buffalo carp. The highest PCB levels were measured in a buffalo carp (469ng/g) and a yellow croaker (495ng/g). Species-specific differences in PCB levels accounted for only 6.3% of total variability, in contrast with 39.2% for mercury. Although we did not measure high mean mercury levels in the species we sampled, frequent consumption of fish with low to moderate levels can also elevate blood mercury. The data we collected can be used to guide fish consumption in Asian communities. However, risk-benefit trade-offs also need to be considered.