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Salmonella infections declined after NYC required restaurants to post inspection grades
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In New York City, Salmonella infections declined after the city health department mandated that restaurants post inspection letter grades in their windows, according to findings published in Emerging Infectious Diseases.
“Rates of Salmonella infection in the United States have not declined, despite national efforts to reduce contamination of raw meat, poultry, and egg products,” Melanie J. Firestone, a PhD candidate at the University of Minnesota School of Public Health, told Infectious Disease News. “Restaurants are frequent settings for transmission of Salmonella infections because there are many ways that Salmonella can come into the restaurant, and the complexity of food preparation increases opportunities for Salmonella to contaminate food served to patrons.”
Foodborne pathogens cause 48 million illnesses, 128,000 hospitalizations and 3,000 deaths each year in the U.S., Firestone and co-author Craig W. Hedberg, PhD, professor in the division of environmental health sciences at the University of Minnesota School of Public Health and co-director of the Minnesota Integrated Food Safety Center of Excellence, noted in their report. Restaurants “play a role in the epidemiology of Salmonella infections” and were associated with 60% of all foodborne illness outbreaks in 2015, the authors wrote.
New York state does not have a policy for reporting results of restaurant inspections, but New York City has been using a point-scoring system since 2005. In 2010, the New York City Department of Health and Mental Hygiene (DOHMH) began converting these scores to letter grades of A, B or C and required restaurants to post their grade in the window where customers could see it, Firestone and Hedberg noted.
For their study, they collected laboratory-confirmed Salmonella case counts from 1994 to 2015 from the city and state health departments and compared the rates of Salmonella infection in New York City with the rest of the state before and after the implementation of the letter grade system.
Even before letter grading was implemented, both New York City and the rest of the state experienced a decline in the annual rate of Salmonella infections between 1994 and 2015, according to the study. But the researchers attributed this to the new system being implemented soon after other prevention and control measures were put in place to combat the high rates of Salmonella enteritidis infections in the 1980s.
After the city began requiring restaurant to post letter grades, there was a 5.3% decline per year in Salmonella infections in New York City compared with the rest of the state (95% CI, 0.92-0.98; P < .01), Firestone and Hedberg reported. Firestone said letter grades “promote transparency by triggering a feedback loop that leads to improved sanitary conditions in restaurants.”
“More studies are needed in other states and cities with transparency programs to better understand the potential widespread impact of transparency programs for restaurant inspections and what factors contribute the most to declines in infections,” she said. “Additionally, this study demonstrates the usefulness of Salmonella surveillance data to evaluate the effectiveness of food safety policies and programs. As culture independent diagnostic tests increase the number of people diagnosed, more cases of Salmonella will likely be reported, which provides more Salmonella data and possibly more ways to use it to identify opportunities to reduce risk.” – by Marley Ghizzone
Disclosure: Firestone reports no relevant financial disclosures.
Perspective
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This study was able to show that using letter grades in New York City restaurants and posting them where consumers can see them had an impact on overall rates of rates of foodborne illness. They looked specifically at Salmonella, which is a good choice because it is a pathogen for which we have good data, but I think it would have implications for other types of foodborne illnesses as well. It is often hard to demonstrate the influence and impact of a public health intervention. It is quite impressive that they were able to do it here, and I think they did it convincingly.
Restaurant inspections are a core function of local and state public health and the results are often available to the public. But as a consumer, you must put in a little bit of effort to go in and look at the results of inspections for different restaurants, whereas the letter grade is on the window and you see it on your way in the door. What is notable here is that they did not see this decrease in Salmonella infections with the scoring system alone; Salmonella infections only began to decrease after they started using the scoring system to generate a letter grade and putting that letter grade near the door of the restaurant, so that consumers could easily see it before they entered the restaurant.
The CDC has been working to build capacity within the U.S. by sending states funding for different programs. It seems like at the time this letter grading system was implemented in New York, it had become a Foodborne Diseases Centers for Outbreak Response Enhancement (FoodCORE) center. It was awarded money specifically to enhance foodborne disease surveillance. It is particularly striking that, at a time when the state was given funding to enhance foodborne disease surveillance and you would expect them to find more foodborne illness, that rates of Salmonella started going down.
All counties and jurisdictions are routinely inspecting restaurants. They all have a system and a checklist that they use. In New York, they assigned a numerical value to different things they were inspecting and the score was used to generate a letter grade. Importantly, this score was weighted toward food safety violations associated with an increased risk for foodborne illness. There obviously are a lot of things that an inspector would look at, but you do not want to include factors to influence a restaurant’s score that do not have a direct impact on the safety of the food.
Coming up with a scheme like this in other jurisdictions seems feasible, but there is some pushback about boiling things down to a letter grade. On one hand, there are a lot of things that are inspected, and some are more important for food safety than others. From what I have heard from colleagues in the restaurant industry, they are fearful that boiling it down to a letter is too simple for an issue that is not that simple. You need to understand more about what violations that restaurant might have had. On the other hand, as a consumer, you want to have easy access to this information before you go into a restaurant. I was in New York recently, and as a consumer, I appreciated having the grades posted on the door and it influenced my behavior. So, there is that tension there. What is that balance between not unfairly representing what has happened during an inspection but also making it accessible and interpretable to the average consumer? It could be rolled out everywhere it is logistically feasible. But there is another layer there — the political will to implement it.
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