Understanding the Relationships Between Inspection Results and Risk of Foodborne Illness in Restaurants.

Restaurants are important settings for foodborne disease outbreaks and consumers are increasingly using restaurant inspection results to guide decisions about where to eat. Although public posting of inspection results may lead to improved sanitary practices in the restaurant, the relationship between inspection results and risk of foodborne illness appears to be pathogen specific. To further examine the relationship between inspection results and the risk of foodborne disease outbreaks, we evaluated results of routine inspections conducted in multiple restaurants in a chain (Chain A) that was associated with a large Salmonella outbreak in Illinois. Inspection results were collected from 106 Chain A establishments in eight counties. Forty-six outbreak-associated cases were linked to 23 of these Chain A restaurants. There were no significant differences between the outbreak and nonoutbreak restaurants for overall demerit points or for the number of demerit points attributed to hand washing or cross-contamination. Our analyses strongly suggest that the outbreak resulted from consumption of a contaminated fresh produce item without further amplification within individual restaurants. Inspections at these facilities would be unlikely to detect or predict the foodborne illness outbreak because there are no Food Code items in place to stop the introduction of contaminated food from an otherwise approved commercial food source. The results of our study suggest that the agent and food item pairing and route of transmission must be taken into consideration to improve our understanding of the relationship between inspection results and the risk of foodborne illness in restaurants.

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.

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.