A risk-based restaurant inspection system in Los Angeles County

Association between food control inspection grades and regional incidence of infectious foodborne diseases in Finland

We studied regional food control inspection grades and their relation to regional incidence of domestically acquired foodborne diseases (caused by Campylobacter spp. Salmonella spp. enterohemorrhagic Escherichia coli (EHEC), and Listeria monocytogenes) using food control inspection data of local food business operators and infectious disease data from 2014 to 2019 from Finland. We observed that inferior overall inspection grades were associated with increased incidence of Salmonella infections (p=0.02). Specifically, inferior grades on cleanliness of facilities, surfaces, and equipment were associated with increased incidence of Salmonella infections (p=0.04). For this topical inspection area, a high effect size was also seen for Campylobacter infections (p=0.06). Of the individual inspection items, an association between increased incidence of Campylobacter infections and inferior grades on storage of foodstuffs (p=0.01) and verification of hygiene proficiency (p=0.03) was observed. These results suggest that food control recognizes non-compliances that may predispose to foodborne diseases.

Smart Supervision for Food Safety in Food Service Establishments in China: Challenges and Solutions

ABSTRACT

Foodborne diseases are a burden in countries worldwide. Several countries have successfully implemented policies that establish innovative systems for the inspection and grading of food service establishments (FSEs), which have greatly contributed to a reduction in foodborne diseases. China's government has also responded by developing policies to protect consumers' food safety, including the routine inspection policy and the risk-based grading policy. However, implementation of both policies has been poor to date. The aim of this study was to identify regulatory challenges and design a smart supervision solution. The results of a national survey showed that the major barriers to policy implementation were a heavy individual workload, the high turnover rate of FSEs, lack of a monitoring and evaluation system, lack of social support, low development of food safety training programs in FSEs, and a lack of financing. A smart supervision solution to these challenges was designed based on mobile Internet and two-dimensional (2D) barcode technology. A pilot application in Jilin province assisted local supervisors in carrying out regulatory work on FSEs, which proved the feasibility of smart supervision. This study can be used as an example for food safety supervision in other regions, and it can assist other governments that wish to implement similar policies to ensure food safety in their countries.

HIGHLIGHTS

Dimensioning of the physical area and required number of food handlers for school food services

ABSTRACT Objective We aimed to establish equations for dimensioning of the physical area and determining the required number of food handlers in food services of schools and to compare them with reference equations. Methods It was visited 44 municipalities located in the states of São Paulo (n=36) and Rio de Janeiro (n=8) between 2013 and 2014. The physical area for school food services was evaluated using a measuring tape. For all food services, we calculated the Maximum Attendance Capacity, which is the sum of small and large meals served during the busiest shift. A validated checklist was used to evaluate food safety practices. Linear regression models were developed to establish the proposed equations. Results In total, we evaluated 205 school units. Based on the data, the following equations were established: Equation A: area of production=15.22+(maximum attendance capacity×0.02), which estimates the minimum area needed for a school food service; and Equation B: the number of food handlers=2.17+(maximum attendance capacity×0.002), to determine the minimum number of food handlers needed. These equations were established based on school food services that presented adequate food safety practices (i.e., low health risk). Conclusion It was established new equations for calculating the size of the physical area for school food services and the required number of food handlers. These new equations can be used as a starting point in management planning of a school food service.

The Impact of Risk Perceptions of Food Ingredients on the Restaurant Industry: Focused on the Moderating Role of Corporate Social Responsibility

This study investigated the causal relationships between international tourists’ perceived sustainability of Jeju Island, South Korea and environmentally responsible behavior, revisit intention, and positive word-of-mouth communication. Perceived sustainability was employed as a multidimensional construct comprised of economic, cultural, and environmental aspects. Data were collected from international tourists that visited Jeju Island. The results indicated that environmentally responsible behavior was influenced positively by cultural sustainability, and negatively by environmental sustainability. Revisit intention and positive word-of-mouth communication were significantly affected by the three dimensions of sustainability. Based on the findings, associated implications were suggested for sustainable destination management of Jeju Island.

Food safety in food services in Lombardy: proposal for an inspection-scoring model

The purpose of this study was to elaborate a checklist with an inspection scoring system at national level in order to assess compliance with sanitary hygiene requirements of food services. The inspection scoring system was elaborated taking into account the guidelines drawn up by NYC Department of Food Safety and Mental Hygiene. Moreover the checklist was used simultaneously with the standard inspection protocol adopted by Servizio Igiene Alimenti Nutrizione (Servizio Igiene Alimenti Nutrizione - Ss. I.A.N) and defined by D.G.R 6 March 2017 – n. X/6299 Lombardy Region. Ss. I.A.N protocol consists of a qualitative response according to which we have generated a new protocol with three different grading: A, B and C. The designed checklist was divided into 17 sections. Each section corresponds to prerequisites to be verified during the inspection. Every section includes the type of conformity to check and the type of violation: critical or general. Moreover, the failure to respect the expected compliance generates 4 severity levels that correspond to score classes. A total of 7 food services were checked with the two different inspection methods. The checklist results generated a food safety score for each food service that ranged from 0.0 (no flaws observed) to 187.2, and generates three grading class: A (0.0-28.0); B (29.0-70.0) and C (>71.00). The results from the Ss. I. A. N grading method and the checklist show positive correlation (r=0.94, P>0.01) suggesting that the methods are comparable. Moreover, our scoring checklist is an easy and unique method compared to standard and allows also managers to perform effective surveillance programs in food service.

Towards more consistent and effective food control: learning from the views of food business operators

We surveyed the opinions of Finnish food business operators (FBOs) about the uniformity of local official food control and its importance for dairy, fishery and meat plants. A total of 136 FBOs responded to the questionnaire. Most FBOs considered official food control to be important for food safety and were generally satisfied with its quality. However, they often did not perceive official food control as being uniform, and 23% even considered it arbitrary. Small-sized FBOs were particularly critical of the relevance of control actions. The better the FBOs assessed their cooperation with the inspector, the higher they assessed the quality, uniformity and benefits of official food control. The cooperative approach in control practices should be emphasized to support the positive views of FBOs about official food control, thus promoting food safety. Cross-audits among local food control units are recommended to improve the FBOs' experience of uniformity of food control.

Inspection Frequency, Sociodemographic Factors, and Food Safety Violations in Chain and Nonchain Restaurants, Philadelphia, Pennsylvania, 2013-2014

OBJECTIVES

We explored how restaurant inspection frequency and restaurant neighborhood sociodemographic characteristics are related to food safety inspection outcomes in chain and nonchain restaurants to better understand external factors that may influence inspection outcomes.

METHODS

We categorized the results of restaurant inspections in Philadelphia, Pennsylvania, in 2013 and 2014 by restaurant type (chain or nonchain), inspection frequency (1, 2, or ≥3 per 2-year study period), and violation type (total number of violations, foodborne-illness risk factor violation, or good retail practice violation). We collected 2013 US Census block group sociodemographic data for each restaurant neighborhood. We used nested mixed-effects regression analyses to determine the association between restaurant inspection frequency and inspection violations, as well as between inspection violations and restaurant neighborhood sociodemographic variables, stratified by restaurant type.

RESULTS

Compared with nonchain restaurants, chain restaurants had significantly fewer total violations per inspection (mean [SD]: 6.5 [4.6] vs 9.6 [6.8] violations, P < .001). For nonchain restaurants, an increase from 1 to 2 inspections resulted in 0.8 ( P < .001) fewer mean violations per inspection, and an increase from 1 to ≥3 inspections resulted in 1.6 ( P < .001) fewer mean violations; this association was not seen in chain restaurants. For nonchain restaurants, a higher proportion of black residents in a restaurant neighborhood was associated with 0.6 ( P < .001) fewer mean foodborne-illness risk factor violations but 1.0 ( P < .001) more mean good retail practice violations per inspection.

CONCLUSIONS

A risk-based stratified approach to restaurant food safety inspection frequency, based on whether or not restaurants are part of chains, could reduce the frequency of violations, particularly in restaurants with the most violations.

Inspection Score and Grading System for Food Services in Brazil: The Results of a Food Safety Strategy to Reduce the Risk of Foodborne Diseases during the 2014 FIFA World Cup

In 2014, Brazil hosted one of the most popular sport competitions in the world, the FIFA World Cup. Concerned about the intense migration of tourists, the Brazilian government decided to deploy a food safety strategy based on inspection scores and a grading system applied to food services. The present study aimed to evaluate the results of the food safety strategy deployed during the 2014 FIFA World Cup in Brazil. To assess food safety, an evaluation instrument was applied twice in 1927 food service establishments from 26 cities before the start of the competition. This instrument generated a food safety score for each establishment that ranged from 0.0 (no flaws observed) to 2565.95, with four possible grades: A (0.0-13.2); B (13.3-502.6); C (502.7-1152.2); and pending (more than 1152.3). Each food service received a stamp with the grade of the second evaluation. After the end of the World Cup, a study was conducted with different groups of the public to evaluate the acceptance of the strategy. To this end, 221 consumers, 998 food service owners or managers, 150 health surveillance auditors, and 27 health surveillance coordinators were enrolled. These participants completed a survey with positive and negative responses about the inspection score system through a 5-point Likert scale. A reduction in violation scores from 393.1 to 224.4 (p < 0.001) was observed between the first and second evaluation cycles. Of the food services evaluated, 38.7% received the A stamp, 41.4% the B stamp, and 13.9% the C stamp. All positive responses on "system reliability" presented a mean of 4.0 or more, indicating that the public believed this strategy is reliable for communicating risks and promoting food safety. The strategy showed positive results regarding food safety and public acceptance. The deployed strategy promoted improvements in the food safety of food services. The implementation of a permanent policy may be well accepted by the public and may greatly contribute to a reduction in foodborne diseases (FBDs).

Supplementing Public Health Inspection via Social Media

Foodborne illness is prevented by inspection and surveillance conducted by health departments across America. Appropriate restaurant behavior is enforced and monitored via public health inspections. However, surveillance coverage provided by state and local health departments is insufficient in preventing the rising number of foodborne illness outbreaks. To address this need for improved surveillance coverage we conducted a supplementary form of public health surveillance using social media data: Yelp.com restaurant reviews in the city of San Francisco. Yelp is a social media site where users post reviews and rate restaurants they have personally visited. Presence of keywords related to health code regulations and foodborne illness symptoms, number of restaurant reviews, number of Yelp stars, and restaurant price range were included in a model predicting a restaurant's likelihood of health code violation measured by the assigned San Francisco public health code rating. For a list of major health code violations see (S1 Table). We built the predictive model using 71,360 Yelp reviews of restaurants in the San Francisco Bay Area. The predictive model was able to predict health code violations in 78% of the restaurants receiving serious citations in our pilot study of 440 restaurants. Training and validation data sets each pulled data from 220 restaurants in San Francisco. Keyword analysis of free text within Yelp not only improved detection of high-risk restaurants, but it also served to identify specific risk factors related to health code violation. To further validate our model we applied the model generated in our pilot study to Yelp data from 1,542 restaurants in San Francisco. The model achieved 91% sensitivity 74% specificity, area under the receiver operator curve of 98%, and positive predictive value of 29% (given a substandard health code rating prevalence of 10%). When our model was applied to restaurant reviews in New York City we achieved 74% sensitivity, 54% specificity, area under the receiver operator curve of 77%, and positive predictive value of 25% (given a prevalence of 12%). Model accuracy improved when reviews ranked highest by Yelp were utilized. Our results indicate that public health surveillance can be improved by using social media data to identify restaurants at high risk for health code violation. Additionally, using highly ranked Yelp reviews improves predictive power and limits the number of reviews needed to generate prediction. Use of this approach as an adjunct to current risk ranking of restaurants prior to inspection may enhance detection of those restaurants participating in high risk practices that may have gone previously undetected. This model represents a step forward in the integration of social media into meaningful public health interventions.

Should Weights and Risk Categories Be Used for Inspection Scores To Evaluate Food Safety in Restaurants?

The objective of this study was to verify the characteristics of food safety inspections, considering risk categories and binary scores. A cross-sectional study was performed with 439 restaurants in 43 Brazilian cities. A food safety checklist with 177 items was applied to the food service establishments. These items were classified into four groups (R1 to R4) according to the main factors that can cause outbreaks involving food: R1, time and temperature aspects; R2, direct contamination; R3, water conditions and raw material; and R4, indirect contamination (i.e., structures and buildings). A score adjusted for 100 was calculated for the overall violation score and the violation score for each risk category. The average violation score (standard deviation) was 18.9% (16.0), with an amplitude of 0.0 to 76.7%. Restaurants with a low overall violation score (approximately 20%) presented a high number of violations from the R1 and R2 groups, representing the most risky violations. Practical solutions to minimize this evaluation bias were discussed. Food safety evaluation should use weighted scores and be risk-based. However, some precautions must be taken by researchers, health inspectors, and health surveillance departments to develop an adequate and reliable instrument.

Regulatory Enforcement and Fiscal Impact in Local Health Agencies

Objectives. We used a cross-sectional, retrospective study design to analyze the association between local health agency regulatory activities and revenues from nonclinical fees and fines (NFF).

Methods. We extracted data from the 2010 National Association of County and City Health Officials (NACCHO) Profile Survey, the most recent report including NFF information, and used 2-part multivariable regression models to identify relationships between regulatory activities and revenue. We also interviewed LHD directors on access to revenue from fines.

Results. NFFs generated substantial revenue for most LHDs, increasing in scope and amount with jurisdiction size for all but the largest municipalities. The greatest proportion of net revenue came from public pools, campgrounds and recreational vehicles, and solid waste disposal. For small and mid-sized LHDs, enforcement activities generated revenue in a dose–response pattern, with higher returns for increased activities. LHDs in decentralized governance states collected more NFF revenue than those in centralized states. States vary regarding LHD access to revenue from sanctions.

Conclusions. The fiscal impact of changes in regulatory activity needs careful assessment to avoid unanticipated consequences of applicable law.

Development and Piloting of a Food Safety Audit Tool for the Domestic Environment

Research suggests that consumers often mishandle food in the home based on survey and observation studies. There is a need for a standardized tool for researchers to objectively evaluate the prevalence and identify the nature of food safety risks in the domestic environment. An audit tool was developed to measure compliance with recommended sanitation, refrigeration and food storage conditions in the domestic kitchen. The tool was piloted by four researchers who independently completed the inspection in 22 homes. Audit tool questions were evaluated for reliability using the κ statistic. Questions that were not sufficiently reliable (κ < 0.5) or did not provide direct evidence of risk were revised or eliminated from the final tool. Piloting the audit tool found good reliability among 18 questions, 6 questions were revised and 28 eliminated, resulting in a final 24 question tool. The audit tool was able to identify potential food safety risks, including evidence of pest infestation (27%), incorrect refrigeration temperature (73%), and lack of hot water (>43 °C, 32%). The audit tool developed here provides an objective measure for researchers to observe and record the most prevalent food safety risks in consumer's kitchens and potentially compare risks among consumers of different demographics.

Using a theoretical predictive tool for the analysis of recent health department inspections at outbreak restaurants and relation of this information to foodborne illness likelihood

Because U.S. restaurants are inspected at least annually against criteria in the U.S. Food and Drug Administration Model Food Code, large amounts of data are generated and should be systematically reviewed. The purpose of this study was to determine the relationships among the data obtained through health department inspections, the contributing factors to foodborne illness identified by the Centers for Disease Control and Prevention, and the risks of outbreaks of norovirus, Salmonella, and Clostridium perfringens infection associated with a specific restaurant. These agents were chosen for the analysis because they cause the majority of foodborne illnesses. A theoretical predictive assessment tool was built that extracts data from routine health department inspection reports for specific restaurants to establish a risk profile for each restaurant and identify the likelihood of a norovirus, Salmonella, or C. perfringens outbreak at that restaurant. The tool was used to examine inspection reports from restaurants known to have had confirmed norovirus, Salmonella, and C. perfringens outbreaks. Although evaluation of an extensive data set revealed lack of an overall association between outbreak inspection scores and routine inspection scores obtained at outbreak restaurant locations, certain specific violations were significantly more likely to be recorded. Significant differences in types of violations recorded during outbreak and routine inspections were determined. When risks based on violation type can be identified, targeted actions may be able to be prioritized and implemented to help decrease illnesses.

Health department inspection criteria more likely to be associated with outbreak restaurants in Minnesota

Millions of routine restaurant inspections are performed each year in the United States, and the Centers for Disease Control and Prevention has reported that a majority of foodborne illness outbreaks occur in restaurant settings. In an attempt to relate the data collected during inspections in Minnesota to illness likelihood, data from routine inspections conducted at outbreak restaurants were compared with data from routine inspections conducted at nonoutbreak restaurants. The goal was to identify differences in recorded violations. Significantly more violations were recorded at restaurants that had outbreaks. The majority of these violations were related to contamination in the facility and environment and to food handling procedures. Relative risks also were calculated for violations significantly more likely to occur at locations that had outbreaks of norovirus infection, Clostridium perfringens infection or toxin-type illness, and Salmonella infection. These three pathogens are estimated to cause the majority of foodborne illnesses in the United States. Meta-analysis of composited data for the three pathogens revealed 11 violations significantly more likely (α < 0.05) to be identified during routine inspections at outbreak restaurants than during inspections at nonoutbreak restaurants. Application of this information permits assessment of health department inspection data in a consistent fashion. This approach can help identify criteria more likely to be associated with outbreak locations and allow operators to focus on interventions that will have the most significant impact in higher risk establishments.

Food safety objectives for Listeria monocytogenes in Spanish food sampled in cafeterias and restaurants

To gain more insight into the context of food safety management by public administrations, food safety objectives must be studied. The Valencian administration quantified the prevalence of Listeria monocytogenes in cafeterias and restaurants in this region of Spain between 2002 and 2010. The results obtained from this survey are presented here for 2,262 samples of fish, salad, egg, cold meat, and mayonnaise dishes. Microbiological criteria defined for L. monocytogenes were used to differentiate acceptable and unacceptable samples; more than 99.9% of the samples were acceptable. These findings indicate that established food safety objectives are achievable, consumer health at the time of consumption can be safeguarded, and food safety management systems such as hazard analysis critical control point plans or good manufacturing practices implemented in food establishments are effective. Monitoring of foods and food safety is an important task that must continue to reduce the current L. monocytogenes prevalence of 0.1% in restaurant or cafeteria dishes, which could adversely affect consumer health.

A prolonged outbreak of Salmonella Montevideo infections associated with multiple locations of a restaurant chain in Phoenix, Arizona, 2008

An outbreak of Salmonella serotype Montevideo infections associated with multiple locations of restaurant chain A in Phoenix, AZ, was identified in July 2008. One infected individual reported eating at a chain A catered luncheon where others fell ill; we conducted a cohort study among attendees to identify the vehicle. Food and environmental samples collected at six chain A locations were cultured for Salmonella. Restaurant inspection results were compared among 18 chain A locations. Routine surveillance identified 58 Arizona residents infected with the outbreak strain. Three chain A locations, one of which catered the luncheon, were named by two or more case patients as a meal source in the week prior to illness onset. In the cohort study of luncheon attendees, 30 reported illness, 10 of which were later culture confirmed. Illness was reported by 30 (61%) of 49 attendees who ate chicken and by 0 of 7 who did not. The outbreak strain was isolated from two of these three locations from uncooked chicken in marinade, chopped cilantro, and a cutting board dedicated to cutting cooked chicken. Raw chicken, contaminated before arrival at the restaurant, was the apparent source of this outbreak. The three locations where two or more case patients ate had critical violations upon routine inspection, while 15 other locations received none. Poor hygiene likely led to cross-contamination of food and work areas. This outbreak supports the potential use of inspections in identifying restaurants at high risk of outbreaks and the need to reduce contamination of raw products at the source and prevent cross-contamination at the point of service.

Certified kitchen managers: do they improve restaurant inspection outcomes?

Restaurants are associated with a significant number of foodborne illness outbreaks in the United States. Certification of kitchen managers through an accredited training and testing program may help improve food safety practices and thus prevent foodborne illness. In this study, relationships between the results of routine restaurant inspections and the presence of a certified kitchen manager (CKM) were examined. We analyzed data for 4461 restaurants in Iowa that were inspected during 2005 and 2006 (8338 total inspections). Using logistic regression analysis, we modeled the outcome variable (0 = no critical violations [CVs]; 1 = one or more CVs) as a function of presence or absence of a CKM and other explanatory variables. We estimated separate models for seven inspection categories. Restaurants with a CKM present during inspection were less likely to have a CV for personnel (P < 0.01), food source or handling (P < 0.01), facility or equipment requirements (P < 0.05), ware-washing (P < 0.10), and other operations (P < 0.10). However, restaurants with a CKM present during inspection were equally likely to have a CV for temperature or time control and plumbing, water, or sewage as were restaurants without a CKM present. Analyses by type of violation within the temperature and time control category revealed that restaurants with a CKM present during inspection were less likely to have a CV for hot holding (P < 0.05), but the presence of a CKM did not affect other types of temperature and time control violations. Our analyses suggest that the presence of a CKM is protective for most types of CVs, and we identify areas for improving training of CKMs.

Standardized inspections of food premises during the 2004 Athens Olympic Games: descriptive analysis and risk factors for unsatisfactory results

Standardized inspections of food premises are part of environmental health systems implemented worldwide. The food safety strategy for the 2004 Olympic Games included standardized inspections to ensure uniformity and consistency of procedures and effective electronic management of data. Inspections were carried out by 196 inspectors in the five Olympic cities: Athens, Thessalonica, Volos, Iraklio, and Patra. From January 2003 to September 2004, a total of 1,249 food premises were inspected. An unsatisfactory inspection result (C grade) was received by 347 (27.8%) food premises, a relatively satisfactory result (B grade) was received by 332 (26.6%), and a satisfactory result (A grade) was received by 570 (45.6%). About 16% of inspected premises did not hold a valid permit. Unsatisfactory inspection results were more frequent for premises located in the two largest Greek cities in comparison with the other smaller cities (relative risk = 1.95, 95% confidence interval [CI] = 1.36 to 2.80). Based on logistic regression analysis, unsatisfactory inspection results were positively associated with food premises that were not located on a ground floor (odds ratio [OR] = 2.56, 95% CI = 1.39 to 4.73) and negatively associated with application of hazard analysis critical control point (HACCP) principles (OR = 0.27, 95% CI = 0.10 to 0.71). Food hygiene education through formal training programs should be encouraged to improve compliance of food premises. Food premises located on hotel floors and serving buffet meals are at higher risk for unsatisfactory conditions. Businesses that implemented a HACCP system within their operations to ensure food safety operated under more hygienic conditions. Future inspections by Public Health Authorities should involve elements of audit after the legislation for the application of HACCP principles.

Operational practices associated with foodborne disease outbreaks in the catering industry in England and Wales

Catering businesses continue to be the most common setting for foodborne disease outbreaks. In a study of catering businesses in England and Wales, operational practices relating to the supply, preparation, and service of food in 88 businesses associated with outbreaks were compared with those practices at 88 control businesses. Operational practices did not differ significantly between case and control businesses but larger small medium-size enterprise (SME) businesses were more likely to be associated with foodborne disease outbreaks than were micro-SME businesses. Businesses associated with outbreaks of Salmonella infection were less likely to use local or national suppliers but instead used regional suppliers, especially for eggs. This practice was the only significantly independent operational practice associated with outbreaks of Salmonella infection. Regional egg suppliers also were more likely to be used by businesses associated with outbreaks attributed to food vehicles containing eggs. Businesses associated with egg-associated outbreaks were less likely to use eggs produced under an approved quality assurance scheme, suggesting that the underlying risk associated with using regional suppliers may relate to the use of contaminated eggs.

Are staff management practices and inspection risk ratings associated with foodborne disease outbreaks in the catering industry in England and Wales?

Despite structured enforcement of food hygiene requirements known to prevent foodborne disease outbreaks, catering businesses continue to be the most common setting for outbreaks in the United Kingdom. In a matched case control study of catering businesses, 148 businesses associated with outbreaks were compared with 148 control businesses. Hazard analysis critical control point systems and/or formal food hygiene training qualifications were not protective. Food hygiene inspection scores were not useful in predicting which catering businesses were associated with outbreaks. Businesses associated with outbreaks were more likely to be larger small and medium-sized enterprises (SMEs) or to serve Chinese cuisine and less likely to have the owner or manager working in the kitchen, but when size of the SME was taken into account these two differences were no longer significant. In larger businesses, case businesses were more likely to be hotels and were more commonly associated with viral foodborne outbreaks, but there was no explanation within the data for this association.

Occupational hazards and risks faced by Chinese immigrant restaurant workers

Historically, Chinese immigrants to the United States have worked in restaurants to support their families. Hazards and risks associated with this population's work in restaurants are underrepresented in the literature. This ethnographic study used interviews, participant-observations, and follow-up focus sessions with 18 immigrants from China, Hong Kong, and Taiwan to identify potential physical, biological, enviromechanical, chemical, and psychosocial hazards that they face. Psychosocial hazards were most often mentioned by the participants; biological hazards were not identified in the data. Practice and research implications for addressing health disparities in this population are discussed.

Systematic environmental evaluations to identify food safety differences between outbreak and nonoutbreak restaurants

Restaurants are important settings for foodborne disease transmission. The Environmental Health Specialists Network (EHS-Net) was established to identify underlying factors contributing to disease outbreaks and to translate those findings into improved prevention efforts. From June 2002 through June 2003, EHS-Net conducted systematic environmental evaluations in 22 restaurants in which outbreaks had occurred and 347 restaurants in which outbreaks had not occurred. Norovirus was the most common foodborne disease agent identified, accounting for 42% of all confirmed foodborne outbreaks during the study period. Handling of food by an infected person or carrier (65%) and bare-hand contact with food (35%) were the most commonly identified contributing factors. Outbreak and nonoutbreak restaurants were similar with respect to many characteristics. The major difference was in the presence of a certified kitchen manager (CKM); 32% of outbreak restaurants had a CKM, but 71% of nonoutbreak restaurants had a CKM (odds ratio of 0.2; 95% confidence interval of 0.1 to 0.5). CKMs were associated with the absence of bare-hand contact with foods as a contributing factor, fewer norovirus outbreaks, and the absence of outbreaks associated with Clostridium perfringens. However, neither the presence of a CKM nor the presence of policies regarding employee health significantly affected the identification of an infected person or carrier as a contributing factor. These findings suggest a lack of effective monitoring of employee illness or a lack of commitment to enforcing policies regarding ill food workers. Food safety certification of kitchen managers appears to be an important outbreak prevention measure, and managing food worker illnesses should be emphasized during food safety training programs.

Waterborne diseases prevention: evaluation of inspection scoring system for water sites according to water microbiological tests during the Athens 2004 pre-Olympic and Olympic period

STUDY OBJECTIVES

To evaluate the inspection grading system for water sites implemented during the Athens 2004 Olympic inspection programme.

DESIGN

The relation between the standardised inspections results of 716 water supply systems and 289 public swimming pools, and microbiological test results of 2358 samples collected during inspections was examined.

SETTING

Athens, Thessaloniki, Patra, Volos, and Iraklio, Greece. Inspections and sampling conducted during a two year period before the 2004 Olympics.

MAIN RESULTS

Swimming pools unsatisfactory inspection grading results were significantly associated with positive water microbiological test results (relative risk = 2.5, p<0.05). One of the six violations of swimming pools and five of the seven violations of water supply systems designated as "critical" water safety hazards in the inspection reports were significantly associated with positive microbiological test results. The receiver operating characteristic analysis identified the unsatisfactory score designed in the swimming pools standardised inspection report, as the ideal score (-15), in adequately producing positive microbiological test results (sensitivity 13.2%, specificity 89%).

CONCLUSIONS

This study shows the utility of standardised inspection grading systems in waterborne diseases prevention planning and implementation strategies of policy makers and regulators. Future water quality assessment should be based on the implementation of a robust standardised inspection system and reduce the need of microbiological tests.