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Approximately half of the foodborne disease outbreaks reported to the Centers for Disease Control and Prevention (CDC) each year is associated with restaurants or delicatessens. Currently, there are no federal-level restaurant food safety training or inspection requirements in the United States. As a result, food handler educational requirements and restaurant inspection frequencies vary throughout the country. Correlation of restaurant-related foodborne disease outbreaks with restaurant inspection frequency and food handler training has not been performed at the national level. <P>The specific objectives of the proposed project are as follows: 1) to conduct a cross-sectional epidemiologic study at the national level to determine if frequency of restaurant inspection by local health authority and levels of food handler training are associated with restaurant-related foodborne disease outbreaks when controlling for local demographic factors and 2) to conduct a spatial clustering analysis using Geographic Information Systems (GIS) technology to assess clustering of foodborne disease outbreaks with respect to frequency of restaurant inspections and food handler training requirements. A survey will be designed to determine the policies and practices of the two variables of interest (restaurant inspection frequency and food handler training requirements) and the outcome variable (number of restaurant-related foodborne outbreaks on a local health department level for the years 2009, 2010 and 2011). All 2,864 local health departments across the United States will be invited to participate. Data will be collected electronically with progress evaluated by the percentage of completed surveys at specific time points: 25% survey completion by April 2013, 50% completion by August 2013 and 100% completion by December 2013. Following data collection, data will be merged, cleaned and analyzed using SAS, STATA and GIS. The Advisory Committee will be updated quarterly on the progress of the project. <P>Study results will be disseminated using various avenues, including presentation at the UIC weekly seminar, abstract submission for presentation at food safety and public health conferences, and manuscript submission to peer-reviewed journals. Dissemination activities will primarily occur in Year 2 of the study. Education and training activities will be completed throughout the course of the project. The Global Information System (GIS) training course, NEHA Epi-Ready Team Training: Foodborne Illness Response Strategies, ServSafe Certification and one CDC TRAIN online food safety course will be completed by August 2013. The STATA training course and two additional TRAIN online food safety courses will be completed by August 2014.
Non-Technical Summary:<br/>
As there is a substantial foodborne disease burden in the United States with a considerable proportion of outbreaks attributed to restaurants, a reduction in restaurant-related foodborne disease outbreaks is crucial to improve the overall health of Americans. There is great need to further examine the risk factors contributing to restaurant-related foodborne disease outbreaks. Restaurant inspection frequency and food handler training requirements are such factors that deserve attention. Currently, there are no federal-level restaurant food safety training or inspection requirements in the United States. As a result, food handler educational requirements and restaurant inspection frequencies vary throughout the country. Correlation of restaurant-related foodborne disease outbreaks with restaurant inspection frequency and food handler training has not been performed at the national level. If there is indeed an association between frequency of foodborne disease outbreaks and inspection and training requirements when controlling for local factors, there is the potential to improve upon existing restaurant food safety policy. The data from this research may help to inform local and state health authorities about the minimum necessary restaurant inspection frequency and food handler training requirements (and therefore minimum investment of time and money) while maintaining the confidence that they have implemented the best level of intervention to prevent foodborne disease. The results from this study may also impart the push needed to increase standards in localities which are shown to be performing inspections and training at levels lower than are needed for maximum food safety. Furthermore, the results could serve as a means to formulate a list of best practices to be adopted by all health departments. Since there is currently no national regulation for restaurant inspections and food handler training in the United States, this work has the potential to significantly improve food safety on a national level.
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Approach:<br/>
A local health department survey will be developed to collect the following information; required number of inspections per year for each restaurant type, number of inspections actually performed, number of health inspectors employed by the jurisdiction, number of inspections each sanitarian performed by month each year, type of inspection forms/systems used, required food handler education, number of restaurant-related foodborne outbreaks, number/type of food handler training facilities, number/classification of restaurants, number of restaurants with critical food safety violations, number of restaurant closures due to food safety malpractice. All 2,864 local health departments across the United States will be invited to participate and data will be collected electronically using the secure web survey program SurveyGizmo. Additional variables of interest will be obtained from various sources. Restaurant census information will be obtained from the 2007 Economic Census and will include: the number of restaurants in each US state, county and city, restaurant demographics (including restaurant type, average business income). Population census information will be obtained from the 2010 Census and will include: number of persons in each US state, county and city, population demographics (including median household income, education, racial/ethnic/ characteristics). Outbreak information will be obtained from the 2009 Centers for Disease Control and Prevention (CDC) Foodborne Outbreak Online Database (FOOD) and will include: outbreak location by state, number of persons sick, hospitalized and died, reported and confirmed outbreaks, causative agents and suspected food vehicles. Numbers of restaurant-related outbreaks and outbreak characteristics will be examined at the state-level to assess consistency in outbreak reporting in this study compared to the CDC. Data from the survey, 2009 FOOD, the 2007 US Economic Census dataset and the 2010 US Census population dataset will be merged together for analysis. Data will be analyzed using both SAS and STATA statistical packages. Descriptive information will be provided as the survey data is collected. Regression models will be employed to analyze number of restaurant-related foodborne outbreaks outcome with number of restaurant inspections and food handler education and other potential confounders. Geographic Information System (GIS) analysis will be utilized, and choropleth maps will be prepared to visualize the area outbreak data. Restaurant-related foodborne-illness outbreak prevalence, reported cases, confirmed cases and causative-agent specific cases will be analyzed. Study results will be disseminated using various avenues including presentation at the UIC weekly seminar, abstract submission for presentation at food safety and public health conferences and manuscript submission to peer-reviewed journals. An Advisory Committee of food safety, public health and survey development experts has been established and will serve to evaluate the progress of the study. Members will be updated quarterly to ensure that outputs are being accomplished according to the study timeline and protocol.