Epidemiology of restaurant-associated foodborne disease outbreaks, United States, 1998-2013

Effectiveness of Online Food-Safety Educational Programs: A Systematic Review, Random-Effects Meta-Analysis, and Thematic Synthesis

Online food-safety educational programs are increasingly important to educate different populations as technology and culture shift to using more technology. However, the broad effectiveness of these programs has yet to be examined. A systematic review, random-effects meta-analysis, and thematic synthesis are conducted to identify the effect size of online food-safety educational programs on knowledge, attitudes, and practices of consumers, food workers, and students and their respective barriers and recommendations. Online food-safety education was found to be of moderate and low effectiveness, with attitudes being the lowest in all populations. Consumers struggled with staying focused, and it was found that messaging should focus on risk communication. Students struggled with social isolation and a lack of time, and it was recommended that videos be used. Food workers struggled with a lack of time for training and difficulty understanding the material, and future programs are recommended to implement shorter but more frequent trainings with simple language. Future online food-safety educational programs should focus on incorporating social elements, as they can remain a huge barrier to learning. They should also focus on changing the participant's attitude to risk perception and beliefs in the importance of food safety.

Methods and measures in food service food safety research: A review of the published literature

Purpose

Food handlers working in food service establishments need to perform appropriate and consistent food safety practices to ensure that the prepared food is safe for consumers to eat, as a failure to do so may lead to foodborne illness. It is important to have an in-depth understanding of food handler food safety behaviour in the food service sector to design targeted educational interventions and approaches to safeguard consumers. The purpose of this review is to provide insight to the existing body of research regarding food handler food safety in the food service sector, and to identify future research needs in terms of methods and measures.

Methods

This study is a review of published food safety research studies (n = 118) focusing on food handlers in the food service sector conducted between 2001 and 2021. Data were collated regarding the methods used and the measures assessed in published studies to identify the gaps in current knowledge related to food safety in food service.

Findings

The majority of studies were conducted in the United States (29%), Brazil (17%) and United Kingdom (7%). A large proportion were carried out in restaurants (70%). Less than a third of studies (28%) relied on a mixed method approach for data collection; and only 12% of studies assessed a combination of cognitive and behavioural measures. Observation was used in only 29% of studies. A lack of observational data detailing food safety practices such as handwashing, temperature control, separation and cleaning was determined.

Significance

Such findings indicate a greater need for mixed method approach in future food safety research. It is recommended that the understanding of food handler food safety performance is best obtained through a combined assessment of cognitive and behavioural measures with subsequent triangulation of findings to reduce bias and to obtain reliable results.

Food Safety Practices of Food Handlers in China and their Correlation with Self-reported Foodborne Illness

Food service facilities are important sites where foodborne diseases have been reported to occur frequently. This study aims to determine the correlation between self-reported foodborne diseases and food-safety practices followed by food handlers of various food service facilities. A cross-sectional survey was conducted from March 1, 2022 to December 30, 2022 in Wuhu City, Anhui Province, China. Data were collected through face-to-face interviews and having the selected food handlers fill in a self-compiled questionnaire. Of the 1072 food handlers included in the study, 88 (8.2%) reported having experienced symptoms of foodborne diseases in the past 4 weeks. The following food-safety practices correlated with self-reported foodborne diseases: (1) infrequently using 3-compartment sinks to separately clean different types of raw food materials (P < 0.05, OR = 2.312); (2) infrequently removing non-edible parts of aquatic products outside a specific room for food processing (P < 0.001, OR = 3.916); (3) infrequently immediately refrigerating cold dishes prepared in advance to be consumed later (P < 0.001, OR = 4.048); (4) often store perishable foods at 8-60°C in the indoor environment after cooking and before eating (P < 0.05, OR = 2.068); (5) infrequently reheating cooked perishable food stored at 8-60°C for more than 2 h before eating (P < 0.05, OR = 1.934); and (6) often storing raw and cooked food in the same container (P < 0.001, OR = 3.818). Hence, a better supervision of food-safety practices of catering workers may reduce the frequency of foodborne-disease outbreaks in food service facilities.

Evaluation of the Handling Practices and Risk Perceptions of Dried Wood Ear Mushrooms in Asian Restaurants in the United States

In late 2020, dried wood ear mushrooms, a low-moisture food ingredient that had been imported and sold to restaurants, were linked to a foodborne outbreak of Salmonella Stanley, which sickened 55 individuals across the United States. These mushrooms are commonly used in Asian cuisine. It is unclear if the contaminated dried wood ear mushrooms that caused the foodborne illnesses were improperly handled during preparation. The objectives of this study are to assess the handling practices, risk perceptions, and food recall experiences of dried wood ear mushrooms in restaurant kitchens among Asian restaurant managers and chefs. We conducted a series of telephone interviews with managers and chefs of Asian restaurants in the United States who used dried wood ear mushrooms in making dishes. After reaching information saturation, a total of 25 restaurant managers and chefs participated in the interview. Our results showed that 76% of the participants did not keep track of package information, such as expiration date and lot number, and many participants reported using cold water for rehydration. Wood ear mushrooms were blanched before being used in all cold dishes and most stir-fry dishes, but less commonly in stew or ramen. Some participants (16%) did not view dried wood ear mushrooms as a raw food ingredient, and 16% did not perceive that low-moisture food ingredients constituted microbiological food safety risks. The majority of the participants had heard of food recalls, but only 17% knew about the dried wood ear mushroom recall, and even fewer had heard of food recalls of other low-moisture foods, like nuts and seeds (9%), and flour (4%). While this study shares similarities with previously published studies evaluating the handling practices of consumers and restaurant employees with respect to meat and poultry, it makes a distinctive contribution to the field of food safety as the first-of-its-kind to study the handling practices of a low-moisture food ingredient: dried wood ear mushrooms. This unique ethnic food ingredient has been associated with a past outbreak and multiple recalls in the United States. The findings of the study show the need to develop food safety educational programs that are tailored toward Asian restaurant food handlers and provide guidance to develop risk communication strategies for this niche audience.

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.

Investing in Retail Food Safety: Assessing the NEHA-FDA Retail Flexible Funding Model Grant Program's Distribution Through an SDOH Lens

Social Determinants of Health (SDOH) have a major impact on community health and quality of life. Healthy People 2030 has an increased focus on SDOH, given their contribution to health disparities and inequalities as a social phenomenon. Despite advances in food hygiene and sanitation, structural disparities related to SDOH leave food systems vulnerable. The Voluntary National Retail Food Regulatory Program Standards (VNRFRPS), otherwise known as the Retail Program Standards initiative is part of the Food and Drug Administration (FDA)'s strategy for prevention-based food safety to reduce foodborne illness. The National Environmental Health Association (NEHA) and the U.S. Food and Drug Administration (FDA) work in partnership to administer the NEHA-FDA Retail Flexible Funding Model (RFFM) Grant Program. The program provides funding to State, Local, Tribal, and Territorial (SLTT) retail food regulatory agencies as they achieve and advance conformance with the VNRFRPS. In its first year (Calendar Year 2022) of the 3-year cycle, the grant program awarded $6.87M in funding to over 200 jurisdictions nationwide. The research note shares preliminary findings of utilizing Geographic Information Systems (GIS) to map the first-year SLTT grant program awardees, with a selection of their jurisdiction's Social Determinants of Health (SDOH) metrics. Integration and analysis of program-specific grant funding and mapping with the relevant health determinants provide an opportunity to understand further the need for comprehensive program investments for greater impact and improvements in public health.

The role of hands in cross-contamination of kitchen surfaces during meal preparation

BACKGROUND

Foodborne pathogen transmission during food preparation is a common occurrence, and cross-contamination can be a contributing factor. Behaviors that lead to cross-contamination during meal preparation have not been well characterized. The study objective was to determine how hands and food handling behaviors (with a focus on handwashing and touch-based events) affect the risk of cross-contamination of kitchen surfaces and foods during meal preparation.

METHODS

Data from a prior study in which participants were observed preparing turkey burgers inoculated with bacteriophage MS2 and a salad provided the data for analysis. Cross-contamination was assessed using environmental sampling data. Behavioral coding was performed for handwashing and touch-based behaviors. Cross-contamination risk was defined as the likelihood (number of contaminated surfaces) and degree (contaminant concentration) of MS2 on surfaces. Statistical analyses were performed in R, SPSS, and SigmaPlot.

RESULTS

The significantly reduced risk of cross-contamination (P.ß<.ß.0001) was observed for participants who attempted handwashing or completed more handwashing steps. Scrubbing hands for 5.ßseconds, on average, reduced the risk of cross-contamination (P.ß<.ß.05). Cross-contamination regression models created using the most significant predictor variables showed that increased handwashing attempts, completion of more handwashing steps, and average scrub times>5.ßseconds all decreased the risk of cross-contamination (P.ß<.ß.05).

CONCLUSIONS

This analysis can be used in future risk assessment modeling and for informing education and outreach to reduce pathogen transmission during food preparation.

Two successive outbreaks of acute gastroenteritis due to norovirus GII.6 in a holiday camp house

When two outbreaks occur in the same institution within a short period of time, an important health and social concern is generated. Two gastroenteritis outbreaks occurring a week apart in the same facility were reported in Lleida, Spain, in 2018. The objective of this study was to describe the clinical, epidemiological and microbiological investigation carried out and to determine the risk factors. Demographic data, food consumption and symptoms were collected. Health inspections of the facility were carried out. Risk ratio and their 95% confidence intervals were estimated for the implication of each food consumed. The attack rate was 89.7% in the first outbreak and 69.6% in the second outbreak. The most frequent symptoms in the first and second outbreak were abdominal pain (88.5% and 100%, respectively), vomiting (80.8% and 87.5%, respectively) and nausea (69.2% and 81.3%, respectively). The first outbreak was associated with the consumption of a salad and the second with a cheese omelet. Norovirus GII.6 was detected by RT-PCR and sequenced in both groups of students and in the food handlers who prepared the meals. These results highlight the importance of exclusion from work of food handlers with gastroenteritis, the adequate availability of mechanisms for correct hand washing and the correct cleaning of surfaces.

Impact of the COVID-19 Pandemic on Food Safety Inspection Outcomes in Toronto, Canada: A Bayesian Interrupted Time Series Analysis

The coronavirus (COVID-19) pandemic resulted in major disruptions to the food service industry and regulatory food inspections. The objective of this study was to conduct an interrupted time series analysis to investigate the impact of the COVID-19 pandemic on food safety inspection trends in Toronto, Canada. Inspection data for restaurants and take-out establishments were obtained from 2017 to 2022 and summarized as weekly counts of inspections, pass ratings, and total infractions. Bayesian segmented regression was conducted to evaluate the impact of the pandemic on weekly infraction and inspection pass rates. On average, a 0.31-point lower weekly infraction rate (95% credible interval [CI]: 0.23, 0.40) and a 2.0% higher probability of passing inspections (95% CI: 1.1%, 3.0%) were predicted in the pandemic period compared to prepandemic. Models predicted lower infraction rates and higher pass rates immediately following the pandemic, with additional variability compared to the prepandemic period, that were regressing back toward pre-pandemic levels in 2022. Seasonal effects were also identified, with infraction rates highest in April and pass rates lowest in August. The COVID-19 pandemic resulted in an initial positive effect on food safety outcomes in restaurants and take-out food establishments in Toronto, but this effect appears to be temporary. This finding could be due to the beneficial impact of COVID-19 protection measures in these establishments or other factors such as less volume of customers. Additional research is needed to investigate causes of the identified differences as well as seasonal and long-term inspection trends postpandemic. Results can inform future food safety inspection planning, outreach, and pandemic preparedness.

Food Safety Knowledge among Professional Food Handlers in Slovenia: The Results of a Nation-Wide Survey

The authors present and discuss the results of a nation-wide survey on food safety knowledge among professional food handlers in Slovenia. The data were collected via a telephone survey using a well-established questionnaire adapted to the Slovenian context. Altogether, 601 respondents from hotels, restaurants, catering, and confectionery units completed the questionnaire. To assess food safety knowledge among food handlers in both general and specific domains, three indexes (a General Knowledge Index, a Personal Knowledge Index, and a Temperature Knowledge Index) were created. Among them, the Temperature Knowledge Index revealed the largest gaps in knowledge. An insufficient transfer of food safety knowledge from managers and chefs to assistant chefs and kitchen assistants in establishments where more persons handle food was evident, while a course titled "Hygiene Minimum" of standardised training from the past still significantly contributes to food safety knowledge. The results suggest a need for improvement in the current system of food safety training courses for professional food handlers in Slovenia. The human factor in the food supply chain still has a significant role in ensuring food safety culture, and therefore must become a more important part of the food safety management system.

Epidemiological Features of Foodborne Disease Outbreaks in Catering Service Facilities - China, 2010-2020

Introduction

In terms of food preparation settings, catering service facilities have been identified as locations with the highest incidence of foodborne disease outbreaks in China. Since 2010, the China National Center for Food Safety Risk Assessment has established the Foodborne Disease Outbreak Surveillance System (FDOSS) to monitor foodborne disease outbreaks. Consequently, data from the FDOSS has provided a more accurate depiction of the epidemic characteristics of outbreaks within these facilities.

Methods

From 2010 to 2020, the FDOSS gathered data related to the prevalence of outbreaks, cases, hospitalizations, and deaths linked to foodborne disease outbreaks in catering service facilities. This study examined the temporal and geographical distribution, pathogenic factors, and contributing variables of these outbreaks over the course of the decade.

Results

From 2010 to 2020, China's catering service facilities reported 18,331 outbreaks, which resulted in 206,718 illnesses, 68,561 hospitalizations, and 201 deaths. The second and third quarters of the year accounted for 76.12% of the outbreaks and 72.93% of the cases. The primary pathogenic factors were pathogenic organisms, which caused 4,883 (26.64%) outbreaks, 94,047 (45.50%) cases, 32,170 (46.92%) hospitalizations, and 21 (10.45%) deaths. There were 5,607 (30.59%) outbreaks in restaurants, 2,876 (15.69%) outbreaks from street vendors, and 2,560 (13.97%) outbreaks in employee canteens in China.

Conclusions

The implementation of relevant control methods, including health education and promotion, is critical for addressing foodborne diseases in catering service facilities. Regular food safety training sessions for restaurant personnel and managers are essential to ensuring the effective management of these health risks.

Risk Factors for Non-O157 Shiga Toxin-Producing Escherichia coli Infections, United States

Shiga toxin-producing Escherichia coli (STEC) causes acute diarrheal illness. To determine risk factors for non-O157 STEC infection, we enrolled 939 patients and 2,464 healthy controls in a case-control study conducted in 10 US sites. The highest population-attributable fractions for domestically acquired infections were for eating lettuce (39%), tomatoes (21%), or at a fast-food restaurant (23%). Exposures with 10%-19% population attributable fractions included eating at a table service restaurant, eating watermelon, eating chicken, pork, beef, or iceberg lettuce prepared in a restaurant, eating exotic fruit, taking acid-reducing medication, and living or working on or visiting a farm. Significant exposures with high individual-level risk (odds ratio >10) among those >1 year of age who did not travel internationally were all from farm animal environments. To markedly decrease the number of STEC-related illnesses, prevention measures should focus on decreasing contamination of produce and improving the safety of foods prepared in restaurants.

Esnaf Lokantalarında Kullanılan Kesme/Doğrama Tahtalarının Gıda Güvenliği Açısından Değerlendirilmesi: İstanbul Örneği

Amaç: Çalışma, gastronomi kültürünün vazgeçilmez bir unsuru olan esnaf lokantalarında gerçekleşmesi olası kritik halk sağlığı ve gıda güvenliği risklerinin başında gelen kesme/doğrama tahtalarından kaynaklı mikrobiyal risklerin belirlenmesi amaçlanmıştır.Yöntem: Çalışma kapsamında İstanbul’un ilçeleri Büyükçekmece, Çatalca ve Silivri’de faaliyet gösteren esnaf lokantalarının mutfaklarında kullanılan kesme/doğrama tahtaların yüzeylerinden steril swap ile mikrobiyolojik numuneler alınmıştır. Numuneler uygun sıcaklık ve sürede inkübasyona bırakılarak, toplam mezofilik aerobik bakteri, Staphylococcus aureus, Escherichia coli ve küf-maya sayımı yapılmıştır.Bulgular: Kesme/doğrama tahtalarının yüzeylerinden alınan mikrobiyolojik numunelerde Staphylococcus aureus, Escherichia coli, toplam mezofil aerob bakteri sayısı ve küf - maya sayısının ortalamaları sırasıyla 0,74; 0,61; 1,53 ve 1,21 logkob/10 cm2 tespit edilmiştir. Numunelerde değişik sayılarda Staphylococcus aureus tespit edilmesi personel kaynaklı bir kontaminasyona ve yine değişik sayılarda Escherichia coli tespit edilmesi ise fekal kaynaklı bir kontaminasyona işaret etmektedir.Sonuç: Esnaf lokantalarının gıda güvenliği uygulamalarından biri olan iyi üretim uygulamalarına yeterince uyulmadığı tespit edilmiştir. Esnaf lokantalarında gıda güvenliğinin tamamen sağlanabilmesi için Hazard Analysis and Critical Control Point - Tehlike Analizleri ve Kritik Kontrol Noktaları (HACCP) gibi gıda güvenliği kontrol sistemlerinin de etkin şekilde uygulanması gerektiğini ifade etmek mümkündür.

Food Safety Issues Related to Eating In and Eating Out

Because of growing urbanization and lack of time to prepare meals at home, eating out or getting food delivered have become common trends for many people. The consumption of food from unknown sources may impose an increased chance of contamination with microbiological hazards, especially if sanitary conditions are not met. We evaluated data from health surveillance agencies and scientific articles on foodborne diseases (FBD) reported internationally according to the exposure sites. We observed that the data are influenced by cultural, political, and socioeconomic differences. For instance, in New Zealand, Australia, United States, Denmark and India, the occurrence of FBD outbreaks was greater from foods prepared in commercial establishments and street vendors than from households. Conversely, in China, countries of the European Union and Brazil, the results are the opposite. Additionally, the pandemic imposed new eating behavior patterns, increasing delivery services and foods prepared in so-called "Dark Kitchens". The underreporting and heterogeneity of data among countries prevented a precise conclusion to the question of whether homemade foods are inherently safer than foods prepared out. Nevertheless, a lower level of development in a country influences its sanitation conditions, as well as the number of street food vendors, the search for cheaper foods, and insufficient knowledge of the population on good hygiene practices, which can all increase the chances of FBD cases.

Evaluation of the Impact of Compliance with Mitigation Strategies and Frequency of Restaurant Surface Cleaning and Sanitizing on Control of Norovirus Transmission from Ill Food Employees Using an Existing Quantitative Risk Assessment Model

ABSTRACT

Reduction of foodborne illness caused by norovirus (NoV) continues to be a focus for the food safety community. Using a previously published quantitative risk assessment model, we evaluated more than 60 scenarios examining the impact of implementation of and compliance with risk management strategies identified in the U.S. Food and Drug Administration Food Code for (a) surface cleaning and sanitizing, (b) hand hygiene, (c) exclusion, or (d) restriction of ill employees. Implementation of and compliance with hand hygiene and ill food employee exclusion strategies had the largest impact on the predicted number of highly contaminated food servings and associated consumer illnesses. In scenarios in which gloves were always worn and hand washing compliance was 90%, the model estimated reductions in the number of highly contaminated food servings and ill consumers to 39 and 43% of baseline estimates (i.e., typical practice), respectively. Reductions were smaller when gloves were never worn. Hand washing compliance after using the restroom strongly impacted predicted numbers of highly contaminated servings and consumer illnesses. Ten percent compliance with removing or excluding ill food employees was predicted to increase the number of highly contaminated food servings and ill consumers to 221 and 213% of baseline estimates, respectively. Ninety-four percent compliance with exclusion of ill food employees was predicted to decrease these numbers to 69 and 71% of baseline estimates, respectively. Surface cleaning in food establishments had a relatively small impact on these measures. Restriction of food employees (removed from contact with food and food contact equipment and utensils) was not effective for reducing NoV illness unless this restriction included additional provisions. The results from this study can help risk managers prioritize mitigation strategies and their implementation for controlling the transmission of NoV and subsequent consumer foodborne illness.

HIGHLIGHTS

Food hygiene practices and determinants among food handlers in Ethiopia: a systematic review and meta-analysis

Background

Food-borne diseases are a major public health concern worldwide, particularly in low and middle-income countries (LMICs), such as Ethiopia. Poor food hygiene practices primarily exacerbate food-borne illness transmission. Prior studies on the food hygiene practices among food handlers in Ethiopia were inconsistent. Therefore, this meta-analysis and systematic review aimed to estimate the pooled proportion of good food hygiene practices and identify the determinants in Ethiopia.

Methods

The preferred reporting items for systematic review and meta-analysis (PRISMA) instruments were used, and a systematic search was performed in the PubMed/MEDLINE, POPLINE, HINARI, Science Direct, Cochrane Library databases, and Google Scholar were systematically last searched on the 24th February 2022 for relevant articles. Only the observational studies that reported the proportion of good food hygiene practices and their associated factors among food handlers were included. The quality of the included studies was assessed by two independent authors. Articles with unclear methodologies and did not report the overall proportions of good food hygiene practice were excluded. The effect estimates for pooled proportion and pooled odds ratio (POR) along with a 95% confidence interval (CI) were determined conducting using DerSimonian–Laird's random effect model.

Results

Among 817 retrieved studies, 23 eligible articles with a total sample size of 7153 study participants were included in the meta-analysis. The pooled proportion of good food hygiene practices among food handlers was 50.5% [95% CI: (41.6, 59.4%]; I² = 98.7%, p value = 0.001]. Food handlers with formal education (POR = 4.60, 95% CI: 3.05, 6.93), good knowledge (POR = 1.98, 95% CI: 1.26, 3.11), training (POR = 3.52, 95% CI: 2.35, 5.28), and a positive attitude (POR = 3.41, 95% CI: 2.52, 4.61) about food hygiene components, as well as regular medical checkups (POR = 6.75, 95% CI: 4.49) were significantly associated with good food hygiene practice.

Conclusions

Only half of Ethiopia's food handlers had good food hygiene practice.

Implication of the study

The key elements of effective food hygiene practice that will aid in the development of feasible interventions to increase food handler compliance with food hygiene components have been identified.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41182-022-00423-6.

Fate of Clostridia and other spore-forming Firmicute bacteria during feedstock anaerobic digestion and aerobic composting

Pathogenic spore-forming Firmicutes are commonly present in animal and human wastes that are used as fertilizers in crop production. Pre-treatments of organic waste prior to land application offer the potential to abate enteric microorganisms, and therefore reduce the risk of contamination of crops or adjacent water resources with pathogens carried in these materials. The inactivation and reduction of gram-positive spore formers such as Clostridium spp., Clostridioides spp. and Bacillus spp. from animal and human waste can be challenging given the recalcitrance of the spores these bacteria produce. Given the significance of these organisms to human and animal health, information concerning spore-forming bacteria inactivation during anaerobic digestion (AD) and aerobic composting (AC) is required as the basis for recommending safe organic waste management practices. In this review, an assessment of the inactivation of spore-forming Firmicutes during AD and AC was conducted to provide guidance for practical management of organic matrices of animal or human origin. Temperature and pH may be the main factors contributing to the inactivation of spore-forming Firmicutes during batch lab-scale AD (log reduction <0.5-5 log). In continuous digesters, wet AD systems do not effectively inactivate spore-forming Firmicutes even under thermopholic conditions (log reduction -1.09 - 0.98), but dry AD systems could be a feasible management practice to inactivate spore-forming Firmicutes from organic materials with high solid content (log reduction 1.77-3.1). In contrast, composting is an effective treatment to abate spore-forming Firmicutes (log reduction 1.7-6.5) when thermophilic conditions last at least six consecutive days. Temperature, moisture content and composting scale are the key operating conditions influencing the inactivation of spore-forming Firmicutes during composting. Where possible, undertaking AD with subsequent composting to ensure the biosafety of digestate before its downstream processing and recycling is recommended to abate recalcitrant bacteria in digestate.

A trait-based framework for predicting foodborne pathogen risk from wild birds

Recent foodborne illness outbreaks have heightened pressures on growers to deter wildlife from farms, jeopardizing conservation efforts. However, it remains unclear which species, particularly birds, pose the greatest risk to food safety. Using >11,000 pathogen tests and 1565 bird surveys covering 139 bird species from across the western United States, we examined the importance of 11 traits in mediating wild bird risk to food safety. We tested whether traits associated with pathogen exposure (e.g., habitat associations, movement, and foraging strategy) and pace-of-life (clutch size and generation length) mediated foodborne pathogen prevalence and proclivities to enter farm fields and defecate on crops. Campylobacter spp. were the most prevalent enteric pathogen (8.0%), while Salmonella and Shiga-toxin producing Escherichia coli (STEC) were rare (0.46% and 0.22% prevalence, respectively). We found that several traits related to pathogen exposure predicted pathogen prevalence. Specifically, Campylobacter and STEC-associated virulence genes were more often detected in species associated with cattle feedlots and bird feeders, respectively. Campylobacter was also more prevalent in species that consumed plants and had longer generation lengths. We found that species associated with feedlots were more likely to enter fields and defecate on crops. Our results indicated that canopy-foraging insectivores were less likely to deposit foodborne pathogens on crops, suggesting growers may be able to promote pest-eating birds and birds of conservation concern (e.g., via nest boxes) without necessarily compromising food safety. As such, promoting insectivorous birds may represent a win-win-win for bird conservation, crop production, and food safety. Collectively, our results suggest that separating crop production from livestock farming may be the best way to lower food safety risks from birds. More broadly, our trait-based framework suggests a path forward for co-managing wildlife conservation and food safety risks in farmlands by providing a strategy for holistically evaluating the food safety risks of wild animals, including under-studied species.

Disgusting Face, Disease-Ridden Place?: Emoji Influence on the Interpretation of Restaurant Inspection Reports

Every year, millions of Americans get sick from foodborne illness and it is estimated half of all reported instances occur at restaurants. To protect the public, regulators are encouraged to conduct restaurant inspections and disclose reports to consumers. However, inspection reporting format is inconsistent and typically contains information unclear to most consumers who often misinterpret the inspection results. Additionally, consumers are increasingly searching for this information in a digital context. Limited research explores inspection reports as communication tools. Using affect-as-information and ELM as theoretical frameworks, this experiment investigated how discrete emotions (e.g., disgust) conveyed through pictorial cues (i.e., emojis) influenced consumers' processing of inspection reports. Participants, recruited from Amazon's MTurk, were randomly assigned to one of six experimental conditions in a 3 (emoji: smiling vs. disgusted vs. none) x 2 (violation level: low vs. high) between-subjects design. Then, participants completed a questionnaire regarding perceptions and cognitive processing of the message. Results revealed that, compared to text, disgusted face emoji increased risk perceptions and avoidance behavior. In terms of emotion, smiling face emoji motivated participants to feel more emotions related to sanitation. In turn, positive feelings decreased elaboration likelihood. As predicted by ELM, involvement also predicted elaboration, such that participants who were highly involved with inspection reports elaborated more than those less involved. Involvement also moderated the relationship between emoji presented and elaboration. Practical implications are also discussed.

Trends of Foodborne Diseases in Mississippi: Association with Racial and Economic Disparities

BACKGROUND

Foodborne diseases are a major source of concern in USA. These diseases are a burden on public health and significantly contribute to the cost of health care. There is an urgent need to understand the contributing factors for such outbreaks, especially in Mississippi (MS), an agricultural state with low socioeconomic status.

METHODS

Secondary data for the current study were obtained from the Mississippi State Department of Health (MSDH) Epidemiology department for the study period 2010-2018. Data were for individuals with reported foodborne diseases cases. The data were analyzed to determine the pathogens' trend over time, the highest contributing pathogens to foodborne diseases, the significant geographical variation, and any significant differences in rates based on demographic variables.

RESULTS

Salmonella was the highest contributing pathogen to foodborne disease in MS. The study showed a seasonal variation in the trends of pathogens and a geographical variation, and no racial differences in the incidents of the foodborne diseases was observed.

CONCLUSIONS

Incidence rates of foodborne illness remain high in the state of Mississippi. A better understanding of high levels of foodborne infections caused by Salmonella, Shigella, and Campylobacter resulting from cultural food handling practices or socioeconomic factors will allow to provide guidelines and food safety preventive measures.

Restaurant Date-Marking Practices Concerning Ready-to-Eat Food Requiring Time and Temperature Control for Safety

Certain foods are more vulnerable to foodborne pathogen growth and formation of toxins than others. Lack of time and temperature control for these foods can result in the growth of pathogens, such as Listeria monocytogenes, and lead to foodborne outbreaks. The Food and Drug Administration's (FDA) Food Code classifies these foods as time/temperature control for safety (TCS) foods and details safe cooking, holding, and storing temperatures for these foods. The FDA Food Code also includes a date-marking provision for ready-to-eat TCS foods that are held for >24 h. The provision states that these foods should not be held in refrigeration for >7 days and should be marked with the date or day by which the food should be "consumed on the premises, sold, or discarded." To learn more about restaurants' date-marking practices, the Centers for Disease Control and Prevention's Environmental Health Specialists Network (EHS-Net) conducted observations and manager interviews in 359 restaurants in 8 EHS-Net jurisdictions. Managers reported that they date marked ready-to-eat TCS foods more often than data collectors observed this practice (91% vs. 77%). Observation data showed almost a quarter of study restaurants did not date-mark ready-to-eat TCS foods. In addition, restaurants with an internal date-marking policy date marked 1.25 times more often than restaurants without such a policy and chain restaurants date marked 5.02 times more often than independently owned restaurants. These findings suggest that regulators and the retail food industry may improve food safety and lower the burden of foodborne illness in the United States if they target interventions to independent restaurants and encourage strong date-marking policies.

Food recalls associated with foodborne disease outbreaks, United States, 2006-2016

About 800 foodborne disease outbreaks are reported in the United States annually. Few are associated with food recalls. We compared 226 outbreaks associated with food recalls with those not associated with recalls during 2006–2016. Recall-associated outbreaks had, on average, more illnesses per outbreak and higher proportions of hospitalisations and deaths than non-recall-associated outbreaks. The top confirmed aetiology for recall-associated outbreaks was Salmonella. Pasteurised and unpasteurised dairy products, beef and molluscs were the most frequently implicated foods. The most common pathogen−food pairs for outbreaks with recalls were Escherichia coli-beef and norovirus-molluscs; the top pairs for non-recall-associated outbreaks were scombrotoxin-fish and ciguatoxin-fish. For outbreaks with recalls, 48% of the recalls occurred after the outbreak, 27% during the outbreak, 3% before the outbreak, and 22% were inconclusive or had unknown recall timing. Fifty per cent of recall-associated outbreaks were multistate, compared with 2% of non-recall-associated outbreaks. The differences between recall-associated outbreaks and non-recall-associated outbreaks help define the types of outbreaks and food vehicles that are likely to have a recall. Improved outbreak vehicle identification and traceability of rarely recalled foods could lead to more recalls of these products, resulting in fewer illnesses and deaths.

Occurrence of Escherichia coli and Salmonella species in Some Livestock (Poultry) Feeds in Mando, Kaduna, Nigeria

The study aimed at assessing the proximate composition, isolation, characterization of some Enterobacteriaceae from two (2) brands of poultry feeds marketed in Mando, Kaduna, Nigeria. A total of sixteen (16) samples of two (2) different poultry feeds (starter and finisher) from four (4) poultry farms in mando were collected and subjected to proximate and microbiological analysis. The proximate analysis was carried out using standard techniques and procedures. All the feed samples were cultured on separate media which include Eosin methylene blue (EMB), nutrient Agar (NA) and Salmonella-Shigella Agar (SSA) media using standard procedures. The antibiogram of the selected antibiotics was evaluated against the test isolates. The result of proximate analysis of the starter and finisher feeds indicated that the Dry matter of starter feed had the highest percentage composition of 95.02% and crude fiber of the finisher feed had the lowest composition of 3.78%. The highest number of bacterial load was recorded to be 10.0×104 CFU/g for the feed sample A (starter feed) and 12.0x104CFU/g was recorded for the feed sample B (finisher feed) which had the highest number of bacterial load recorded among the two (2) different poultry feeds analyzed. The bacteria isolates were identified as Salmonella species and Escherichia coli. Total viable count (TVC) of Salmonella species and E. coli in the feed samples (starter and finisher) ranges from 3.0×104CFU/g to 12.0×104CFU/g. Both organisms (Salmonella species, E. coli) were found as 37.5% and 25% of the analyzed feeds (Broiler starter and broiler finisher) samples, respectively. There was no level of significant (p>0.05) difference between the level of contamination of Salmonella species and E. coli in the two different feeds analyzed, as p=0.06 and p=0.13 for Salmonella species, and E. coli respectively. Sample A and B (Starter and Finisher) feeds had the highest number of Salmonella species occurrence with six ( 6) positive samples while E. coli was recorded in four (4) samples of A and B (Starter and Finisher) feeds. The result of the antibiogram indicated that ciprofloxacin (30 µg), Gentamycin (30µg), Perfloxacin (30µg) and Tarvid (30µg) was effective against Salmonella species and Escherichia coli. The significant of spread of the species of the Enterobacteriaceae in livestock feeds requires the need for effective quality assurance and control, good hygiene practices in production and proper handling of the poultry feeds.

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.

HIGHLIGHTS

Metagenomic Analysis of Microbial Composition Revealed Cross-Contamination Pathway of Bacteria at a Foodservice Facility

Bacterial contamination of food-contact surfaces can be a potential risk factor for food quality and safety. To evaluate the spatial and temporal variations of the potential cross-contamination routes, we conducted a biogeographical assessment of bacteria in a foodservice facility based on the diversity of microflora on each surface. To this end, we performed high-throughput amplicon sequencing of 13 food-contact and non-food contact surfaces in a foodservice facility throughout a year. The results showed that Bacillus, Acinetobacter, Streptophyta, Enterobacter, Pseudomonas, Serratia, Enhydrobacter, Staphylococcus, Paracoccus, and Lysinibacillus were the dominant genera found on the kitchen surfaces of the foodservice facility. Depending on the season, changes in Firmicute/Proteobacteria ratios were observed, and the fan becomes the main source of outdoor air contamination. The microbial flow associated with spoilage was also observed throughout food preparation. Taken together, our results would be a powerful reference to hygiene managers for improvement of food processes.

Recent (2011-2017) foodborne outbreak cases in the Republic of Korea compared to the United States: a review

This study analyzes and compares foodborne disease outbreaks reported in the Republic of Korea (KR) and the United States (US) during 2011-2017. The foodborne outbreaks data in the KR and the US were collected from the Ministry of Food and Drug Safety and from the Surveillance for Foodborne Disease Outbreaks United States, respectively. The average number of outbreaks and illness population were higher in the US than in the KR, but the KR's illness ratio considering population size was 2.4 times higher than that of the US. When the sites of outbreaks compared, the number of illness was the highest at schools in the KR whereas outbreaks at restaurants were more frequent in the US. In the KR, bacterial infections were the primary cause of outbreaks while bacterial and viral infections accounted for the largest share of outbreaks in the US. Specifically, pathogenic E. coli presented a significant risk in the KR whereas Salmonella was the most prevalent in the US. These results indicate that the main microbiological targets for detection and control in the KR should differ from the US, which should be considered for developing food safety related policies.

Hand Hygiene Knowledge and Self-Reported Hand Washing Behaviors among Restaurant Kitchen Chefs in Jiangsu Province, China

Inadequate hand washing among chefs is a major contributor to outbreaks of foodborne illnesses originating in restaurants. Although many studies have evaluated hand hygiene knowledge (HHK) and self-reported hand washing behaviors (HWBs) in restaurant workers in different countries, little is known about HHK and HWBs in restaurant kitchen chefs, particularly in China. In this study, we interviewed 453 restaurant kitchen chefs in Jiangsu Province in China regarding their HHK and HWBs and used Chi-square tests (Fisher exact tests), pairwise comparisons, and linear regression models to analyze the responses and identify determinants of HHK and HWBs. Results reveal that less frequent hand washing after leaving work temporarily and after touching used cutlery were the main issues among restaurant kitchen chefs in Jiangsu Province. Kitchen hands had lower levels of HHK and engaged less frequently in good HWBs than the other type of chefs. Furthermore, working in a large restaurant and having worked in the restaurant industry for a longer amount of time were correlated with better HHK and HWBs. These findings suggest that close attention should be paid to the HWBs of chefs during food preparation, that kitchen hands are the key group of restaurant kitchen workers who need training in HHK, and that regulatory activities should focus on small-scale restaurants.

Ethical considerations for mandating food worker vaccination during outbreaks: an analysis of hepatitis A vaccine

A widespread global outbreak of Hepatitis A virus (HAV) has prompted regulations in a few cities in the United States (US) mandating HAV vaccination of food service workers. This Viewpoint considers the global impact of HAV, analyzes ethical issues pertinent to recent mandatory vaccination regulations and the core values of public health. It explores the health and rights of stakeholders and ethical criteria for mandatory vaccination that could be applied globally with the ethical codes of the World Health Organization and the American Public Health Association. The goal is to help create ethical guidance for determining under what conditions, and for what populations, should regulations be created requiring vaccination for a communicable disease.

Food products as potential carriers of SARS-CoV-2

At present, humanity is confronting with a novel life-threatening challenge from the COVID-19 pandemic infectious disease caused by the novel coronavirus SARS-CoV-2. To date, the various transmission modes of SARS-CoV-2 have not been completely determined. Food products might be carriers for SARS-CoV-2. The COVID-19 pandemic not only can spread through the respiratory tract like SARS and MERS but also the presence of the SARS-CoV-2 RNA in feces of several patients, shows the possibility of their fecal-oral route spread. Besides, people with gastric problems, including gastric intestinal metaplasia and atrophic gastritis, may be susceptible to this kind of COVID-19 infection. Accordingly, food may act as a potential vehicle of SARS-CoV-2 due to whether carry-through or carry-over contaminations. Considering carry-over, SARS-CoV-2 spread from personnel to food products or food surfaces is feasible. Beyond that, some shreds of evidence showed that pigs and rabbits can be infected by SARS-CoV-2. Thus, viral transmission through meat products may be conceivable, indicating carry-through contamination. As the spread rate of SARS-CoV-2 is high and its stability in different environments, especially food processing surfaces, is also remarkable, it may enter foods in whether industrialized processing or the traditional one. Therefore, established precautious acts is suggested to be applied in food processing units. The present review elucidates the risk of various staple food products, including meat and meat products, dairy products, bread, fruits, vegetables, and ready-to-eat foods as potential carriers for transmission of SARS-CoV-2.

Pattern of food, drug and chemical poisoning in Qassim region, Saudi Arabia from January 2017 to December 2017

Background

Poisoning has become a widespread and dangerous phenomenon worldwide. The purpose of our study was to determine and analyze the pattern of poisoning cases induced with food, drugs, and chemicals reported to the Department of Environmental and Occupational Health in Qassim province in the Kingdom of Saudi Arabia. The study also evaluated the correlation of demographic variables such as age, type of toxicity and geographical distribution associated with poisoning in Qassim province.

Methods

This retrospective cross-sectional study was performed on 381 cases of poisoning. The data was collected from Jan 2017 to Dec 2017 and revealed that out of 381 cases, 120 have food poisoning (65 % females and 35 % males), 180 have drug poisoning (55.56 % females and 44.44 % males), whereas 81 cases have chemical poisoning (41.98 % female and 58.02 % male). Data were statistically analyzed using SPSS/PC statistical package. The study revealed that the most common agents involved in acute poisoning were drugs (47.25 %), especially analgesics such as Paracetamol (Acetaminophen), followed by antipsychotic drugs. Food poisoning was the second acute poisoning with (31.40 %). Finally, chemical poisoning involved in acute poisoning with 21.20 % of cases reported household products accomplished strongest bleach (chlorines)(Clorox®) and insecticides were the secondary source for chemical poisoning.

Restaurant Policies and Practices Related to Norovirus Outbreak Size and Duration

ABSTRACT

Norovirus is the leading cause of foodborne illness outbreaks in the United States, and restaurants are the most common setting of foodborne norovirus outbreaks. Therefore, prevention and control of restaurant-related foodborne norovirus outbreaks is critical to lowering the burden of foodborne illness in the United States. Data for 124 norovirus outbreaks and outbreak restaurants were obtained from Centers for Disease Control and Prevention surveillance systems and analyzed to identify relationships between restaurant characteristics and outbreak size and duration. Findings showed that restaurant characteristics, policies, and practices were linked with both outbreak size and outbreak duration. Compared with their counterparts, restaurants that had smaller outbreaks had the following characteristics: managers received food safety certification, managers and workers received food safety training, food workers wore gloves, and restaurants had cleaning policies. In addition, restaurants that provided food safety training to managers, served food items requiring less complex food preparation, and had fewer managers had shorter outbreaks compared with their counterparts. These findings suggest that restaurant characteristics play a role in norovirus outbreak prevention and intervention; therefore, implementing food safety training, policies, and practices likely reduces norovirus transmission, leading to smaller or shorter outbreaks.

HIGHLIGHTS

Challenges of investigating a large food-borne norovirus outbreak across all branches of a restaurant group in the United Kingdom, October 2016

During October and November 2016, over 1,000 customers and staff reported gastroenteritis after eating at all 23 branches of a restaurant group in the United Kingdom. The outbreak coincided with a new menu launch and norovirus was identified as the causative agent. We conducted four retrospective cohort studies; one among all restaurant staff and three in customers at four branches. We investigated the dishes consumed, reviewed recipes, interviewed chefs and inspected restaurants to identify common ingredients and preparation methods for implicated dishes. Investigations were complicated by three public health agencies concurrently conducting multiple analytical studies, the complex menu with many shared constituent ingredients and the high media attention. The likely source was a contaminated batch of a nationally distributed ingredient, but analytical studies were unable to implicate a single ingredient. The most likely vehicle was a new chipotle chilli product imported from outside the European Union, that was used uncooked in the implicated dishes. This outbreak exemplifies the possibility of rapid spread of infectious agents within a restaurant supply chain, following introduction of a contaminated ingredient. It underlines the importance of appropriate risk assessments and control measures being in place, particularly for new ingredients and ready-to-eat foods.

Prevalence and characterization of Clostridium perfringens isolated from feces of captive cynomolgus monkeys (Macaca fascicularis)

Clostridium perfringens is ubiquitous in the environment and the gastrointestinal tract of warm-blooded animals. While part of the gut microbiome, abnormal growth of C. perfringens causes histotoxic, neurologic, and enteric diseases in a variety of animal species, including humans, due to the production of toxins. There is extremely limited information on C. perfringens infection in non-human primates. Presently, 10 strains were successfully isolated from 126 monkeys and confirmed by molecular and biochemical analyses. All isolates were genotype A based on molecular analysis. Alpha toxin was identified in all isolates. Beta 2 toxin was detected in only three isolates. No other toxins, including enterotoxin, beta, iota, epsilon, and net B toxin, were identified in any isolate. All isolates were highly susceptible to β-lactam antibiotics. Double hemolysis and lecithinase activity were commonly observed in all strains. Biofilm formation, which can increase antibiotic resistance, was identified in 90% of the isolates. The data are the first report the prevalence and characteristics of C. perfringens isolated from captive cynomolgus monkeys.

Presence of Foodborne Pathogens in Seafood and Risk Ranking for Pathogens

This study aims at examining the contamination of coliform bacteria, Escherichia coli, Listeria monocytogenes, Vibrio vulnificus, and Vibrio cholerae, which carry extremely serious risks to the consumer health, in 700 seafood belonging to 4 different (raw sea fish, raw mussels, raw shrimp, and raw squid) categories. The total number of samples was determined as 700. When the obtained results were viewed in total, they were found to be 48.14%, 18.71%, 8.57%, and 3.42% for coliform bacteria, E. coli, L. monocytogenes, and V. vulnificus, respectively. V. cholerae, one of the factors studied, was not found. Conventional microbiological cultivation methods were used in the analysis stage as well as the real-time PCR method. This study aims at making a risk ranking modeling for consumer health based on product category and pathogens by interpreting the results of the analysis with statistical methods. According to the statistical analysis, significantly binary correlations were determined among some parameters that stimulate one another for reproducing. In the light of the obtained results of the study, it has been concluded that the studies of the most detailed examinations of the microbiological risks associated with seafood, forms of microbial pollution and microorganisms that cause deterioration in seafood and threaten consumer health and the path that their epidemiologies follow, are of primary importance to both protecting consumer health and obtaining safe and quality seafood.

A systematic review and meta-regression of single group, pre-post studies evaluating food safety education and training interventions for food handlers

BACKGROUND

Food handlers working in retail and food service establishments are a frequent source of foodborne disease outbreaks. Numerous studies have investigated different education and training approaches to improve their safe food handling knowledge, attitudes, and practices. Frequently, these studies use a single group, pre-post design, measuring changes before and after an intervention without a separate control group.

OBJECTIVES

We conducted a systematic review of these studies to identify their key characteristics and to evaluate possible predictors of between study heterogeneity in their estimates of intervention effect.

METHODS

the review steps included a comprehensive search; relevance screening; article characterization; risk-of-bias assessment; data extraction; and meta-regression on five outcome categories: attitudes and beliefs, knowledge, behaviours, food premise inspection scores, and aerobic plate counts.

RESULTS

Among 85 relevant studies identified, the most commonly investigated intervention type was in-person, group-based training courses (81%). Interventions primarily targeted food handlers in educational institutions and restaurants (32% and 31%, respectively). The most frequently measured outcome was food handler knowledge (66%). Studies mostly (89%) covered multiple food safety content areas, primarily targeting personal hygiene (88%) and avoiding cross-contamination (87%). All studies were rated as 'critical' risk of bias given the lack of an independent control group. Significant intervention effects were found for all outcome categories, but substantial heterogeneity was also identified. Studies that informed their intervention from formative research reported larger effect sizes for attitude and belief outcomes, those that based their intervention on a theory of behaviour change reported larger effect sizes for behaviour outcomes, and those published in grey literature sources reported larger effect sizes for behaviour and knowledge outcomes.

IMPLICATIONS

The results of this review have identified food safety training and education research gaps and future opportunities.

Effectiveness of Food Handler Training and Education Interventions: A Systematic Review and Meta-Analysis

Improper food handling among those working in retail and food service settings is a frequent contributor to foodborne illness outbreaks. Food safety training and education interventions are important strategies to improve the behaviors and behavioral precursors (e.g., knowledge and attitudes) of food handlers in these settings. We conducted a comprehensive systematic review to identify, characterize, and synthesize global studies in this area to determine the overall effectiveness of these interventions. The review focused on experimental studies with an independent control group. Review methods included structured search strategy, relevance screening of identified abstracts, characterization of relevant articles, risk of bias assessment, data extraction, meta-analysis of intervention effectiveness for four outcome categories (attitudes, knowledge, behavior, and food premise inspection scores), and a quality of evidence assessment. We identified 18 relevant randomized controlled trials (RCTs) and 29 nonrandomized trials. Among RCTs, 25 (64%) unique outcomes were rated as high risk of bias, primarily owing to concerns about outcome measurement methods, while 45 (98%) nonrandomized trial outcomes were rated as serious risk of bias, primarily because of concerns about confounding bias. High confidence was identified for the effect of training and education interventions to improve food handler knowledge outcomes in eight RCT studies (standardized mean difference = 0.92; 95% confidence interval: 0.03, 1.81; I² = 86%). For all other outcomes, no significant effect was identified. In contrast, nonrandomized trials identified a statistically significant positive intervention effect for all outcome types, but confidence in these findings was very low due to possible confounding and other biases. Results indicate that food safety training and education interventions are effective to improve food handler knowledge, but more evidence is needed on strategies to improve behavior change.

Psychosocial and organizational determinants of safe food handling at retail and food service establishments: a systematic review and meta-analysis

Various psychosocial and organizational factors have been investigated as determinants of food handlers' food safety behaviours. A systematic review and meta-analysis of studies in this area was conducted to identify and synthesize the key behavioural determinants. Standard systematic review steps were followed: comprehensive search strategy; relevance screening; article characterization; risk of bias assessment; data extraction; and random-effects meta-analysis. Sixty-two relevant studies were identified, and knowledge was the most commonly investigated behavioural determinant (n = 51). Increased knowledge was consistently associated with safe food handing behaviours across both correlation (r = 0.30; 95% confidence interval [CI]: 0.12, 0.46; n = 24 studies; I² = 98%) and odds ratio (OR) measures (adjusted OR = 1.85; 95% CI: 1.27, 2.70; n = 3; I² = 0%). Seven other behavioural determinant categories were also consistently associated with various food safety behaviour outcomes. In contrast, no association was found between food handler experience and behaviour. The findings can inform the development of targeted training initiatives for food handlers.

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.