Restaurant Inspections And Foodborne Illnesses - Essay Example

Foodborne Illness Caused by Food Establishments Miriam Gonzalez Liberty University Abstract In the United States, one in every six Americans suffers from foodborne illnesses annually leading to five thousand deaths. Texas recorded 202 cases of foodborne illnesses in 2015 alone thus warranting the need for heightened surveillance systems to detect potential risks for outbreaks and execute preventive strategies. 1 Restaurants contribute to the highest proportion of the cases of foodborne illnesses recorded in the United States. This study aims at establishing the association between restaurant inspections and the incidence of foodborne illnesses in Texas. The study utilized a retrospective Cross-Sectional Approach, which is appropriate for generating findings relevant for the subject under investigation. The specific activities will include epidemiological Inspections, forming preliminary standpoint and Future Action, and quantitative data analysis2. Cumulatively 69 outbreaks of foodborne illnesses were reported in Texas in 2014 and 2015. A total of 2107 foodborne illnesses were recorded with a mean of 97.79 and a standard deviation of 189.271. 60% of all the hospitalizations in 2014 and 2015 were recorded in July 2015 whereby 204 individuals were hospitalized. A total of 14 deaths were recorded due to foodborne illnesses with 50% of them occurring in October 2014 while July 2015 accounted for 42.9% of the deaths. Based on these findings, restaurant inspections are very essential in reducing the incidence of foodborne illnesses that contribute to preventable morbidity and mortality in the United States. The routine inspections are useful in identifying gaps that can lead to potential outbreaks, detecting causes for actual outbreaks, and identifying control measures for current outbreaks to prevent further spread. Introduction Globally, foodborne illnesses contribute to a significant proportion of preventable morbidity and mortality leading to huge expenditures in mitigating their advance consequences. In the United States, one in every six Americans suffers from foodborne illnesses annually leading to five thousand deaths. Texas recorded 202 cases of foodborne illnesses in 2015 alone thus warranting the need for heightened surveillance systems to detect potential risks for outbreaks and execute preventive strategies. Restaurants contribute to the highest proportion of the cases of foodborne illnesses recorded in the United States1. The Center for Diseases Control considers foodborne illnesses as a winnable battle through the implementation of cost-effective interventions geared towards breaking the disease cycle. CDC has invested its resources in active surveillance for pathogens responsible for foodborne illnesses and established contingency plans to mitigate potential outbreaks. A proportion of the restaurants in Texas do not meet the prescribed compliance requirements hence the need for restaurant inspectors to work closely with restaurant owners in building their capacity to ensure food safety1. Prevention of foodborne illnesses requires a multi-sectoral approach with the Texas Department of Health strengthening its policies regarding food safety, heightening food inspection activities in eating places, increasing the capacity of food handlers and restaurant owners in food safety, and strengthening community initiatives that target food safety. Restaurant inspections are very useful in the prevention of foodborne illnesses in Texas. The inspection team from the Department of Health spearheads the detection of potential outbreaks, identifies cases of epidemics, establishes the definitive cause of the outbreaks, and rolls out strategies to control and contain the outbreaks thus protecting the public 3. The practicum entailed increasing as well as improving inspection activities to enhance their coverage and building the capacity of food handlers in knowledge and skills to promote food safety through training. Finally, it entailed participation in activities aimed at strengthening adherence to set policies and standards that ensure mobile units use safe food and water from reliable sources. Inspection of restaurants and other eating places has the potential to prevent the majority of the incidences of foodborne illnesses. This is based on the growing challenges associated with food safety namely variations in food production approaches such as imported TCS foods, environmental changes that cause contamination of foodstuff, changes in the bacteria genome leading to antimicrobial resistance, and changing consumer preferences. In Texas, the biggest problem entails the lack of compliance withhold or cold holdings and cross-contamination by most of the restaurants thus making routine inspections inevitable 4. According to a 1997 Scientific Status Summary on “Virus Transmission via Food,” published by the Institute of Food Technologists, nearly all foodborne viruses are spread through feces, and infect others through ingestion hence personal hygiene is an effective control measure for preventing the spread of foodborne. Preventing food contamination by human feces has proven to be tough, thus educating food service workers is a major factor in this control measure 5. Similarly, different species of parasites and bacteria are responsible for foodborne illnesses through various agents hence the need to break the transmission cycles of these pathogens through inspection activities. One–third of Americans have evidence of past infection from Hepatitis A Virus.4Under the right conditions, anyone can get ill from eating contaminated foods. However, the risk and the danger of foodborne illnesses is greater for the highly susceptible population including infants and young children, elderly, pregnant women, those with suppressed immune systems, cancer, and diabetic patients. A foodborne hazard can be biological, chemical or physical; it can cause illness or injury when it is consumed with food. Biological hazards include bacteria, viruses, parasites, and fungi. Biological hazards are normally associated with humans entering the food establishments as well as undercooked, or raw products served to members of the public. Biological hazards are the most important foodborne hazard in food establishments 6. Chemical hazards are toxic substances that can occur naturally or may be added during the processing of food. For example, Benzoates like Benzoic acid, sodium, potassium benzoate and parabens are useful in the inhibition of yeast and mold growth. Nitrites are helpful in curing meat and smoked fish, and inhibit the growth of C. botulinum. Another example is agricultural chemicals (pesticides, fertilizers and antibiotics), cleaning supplies, heavy metals, food additives and food allergens. Physical hazards are hard or soft foreign objects in food that can cause illness, or it can injure a customer of a food establishment 6. Bacteria need six conditions to multiply namely a source of food, moisture, the right pH (4.6 to 7.0), a temperature between 41 F and 135 F, time, acidic environment, and different oxygen requirement. Bacterial growth has four phases namely lag phase, log phase, stationary phase and the decline phase. Time and temperature are the most critical factors that affect the growth of bacteria in foods. Most of the bacteria that causes a disease can grow within a temperature range of 41 F to 135 F known as the Temperature Danger Zone and require about 4 hours to grow to high numbers to cause a foodborne illness. According to the CDC, controlling temperature is the most critical way to ensure food safety. To avoid foodborne illnesses we have to remember this: “hot foods hot, cold food cold, or don’t keep the food at all” 7. The best way to prevent a foodborne illness is by ensuring the cleanliness and personal hygiene of food workers in restaurants and food establishments. Knowing when and how to wash hands, wearing clean clothes properly, keeping healthy personal habits and maintaining good health and reporting when sick can help avoid workers spreading possible infections 8. The FDA Food Code requires that all employees to report to their manager or person in charge when they have been diagnosed with Salmonella typhi, Shigella spp., Shiga-toxin-producing E. coli and Hepatitis A. However, that is not all since employees should also report when they have vomiting, diarrhea, fever, sore throat, or jaundice1. Appropriate guidelines must be followed to create a full proof condition against any pathogenic growth4. The public health system in the country requires establishments that operate in the catering industry, mainly those that sell food to make sure that they adhere to laws and regulations that protect the health of the public6. It the importance of such establishments keeping any food categorized as TCS foods under refrigerated conditions that do not make them harmful for consumption. Failure to follow policies and guidelines on foodborne illnesses prevention could cause an outbreak with disastrous effects on the susceptible populations1. A study by Stanifer et al. (2010), found that the health code violation in ethnic owned restaurants averaged 2.2 critical violations and 4.7 non-critical violations7. Working with food handlers of different cultures can be challenging and can cause a barrier to the implementation of food safety programs and practices. Not being able to explain to them what, when, where and why to do it is problematic and makes food safety training unsuccessful. Enforcing training in ethnic minorities could decrease the critical violations as well as the non-critical violations. Barriers to safe food handling practices for food service establishments are of increasing concern as Americans eat away from home more often 9. The key to preventing foodborne illness is in proper training on food safety and good personal hygiene. Following these two simple concepts reinforced with periodic inspections of restaurants could prevent outbreaks and save many lives. According to the CDC, the ultimate goal for public health is not just stopping outbreaks once they occur, but preventing them from happening in the first place 10. Methods and Justification The study will utilize a Retrospective Cross-Sectional Approach, which is appropriate for generating findings relevant to the subject of investigation 2. In Texas, all restaurants with permits for preparing and serving food must be subjected to semiannual inspections by the existing policy guidelines. The inspection process has an established criterion that comprises of 40 scored items with a possible score of 100. The first part of the inspection sheet is the priority items which includes: proper cooling time and temperature, Proper cold holding temperature (41 F/45F), Proper Hold holding temperature (135F), proper cooking time and temperature, proper reheating procedure for hot holding, time as a Public Health control, food separated and protected during storage, display and tasting among others. The second part of the inspection is called Priority Foundation. Under this section, the person in charge at the restaurant should demonstrate knowledge, and perform specific duties enhancing food safety. All the employees must be certificate food handlers in addition to their certification as Food Managers. There must be a continuous supply of hot and cold-water within the premises, and proper records must be made available including the shell stock tags and parasite destruction. The restaurant must demonstrate its compliance with variance, Specialized Process as well as HACCP plan. In case there are any violations regarding these aspects, corrective actions must be initiated within ten (10) days. The final part of the inspection criterion is referred to as the Core items that comprise of violations which require corrective action not exceeding 90 days or before the subsequent inspection, whichever comes first. Following the inspection, all commercial establishments preparing and serving food items are required to hold a permit from Harris County (Centers for Disease Control). Restaurants remain important settings for foodborne disease outbreaks1 and consumers have increasingly depended on the results of inspection activities in guiding their decisions on where to take meals. It is for this reason that identification of a method for cross-sectional inspection remains essential in improving sanitary practices in the restaurants across Texas and the entire United States of America 4. Since the link between the outbreak of foodborne disease and inspection results appears to be associated with a specific pathogen, there is a need for regular or routine inspections on all restaurants. This study develops a retrospective cross-sectional approach where there will be an inspection of a cohort of restaurants (25 to 30) that share common exposure factors, in this case, foodborne outbreaks or diseases. The aim of identifying the cohorts (25-30 restaurants) is to carry cross-sectional examination so that the results can influence the development and spread of the foodborne disease. The identified cohorts will be compared to other restaurants that were not exposed to foodborne illness3. The approach is feasible considering that the inspector will focus on a sample of restaurants with the desired traits. The inspector will also have mechanisms to deal with the potential recall bias associated with retrospective approaches 11. Description of the Activities 1. Epidemiological Inspections There will be a preliminary assessment of the restaurant where the inspection will start by refuting or confirming the existence of an outbreak thus allowing for working case definitions. The process will entail: Validating the information regarding previous outbreaks of foodborne illnesses Reviewing laboratory test reports on the specific outbreaks detailing the suspected organisms Collection of food samples for further analysis and confirmation in the presence of the potential organisms Interviewing 7-15 persons in every restaurant for the 25-30 fast food restaurants to identify any exposures and additional risk factors for foodborne illnesses The inspector utilized convenience sampling to select the 7-15 respondents or the 25-30 restaurants for purposes of this study. The inspector only considered those establishments that receive payments for the TCS foods they distribute to the customers. The inspector considered the customers who were buying food from these establishments as the respondents and interviewed them during this study. The inspector then applied the existing inspection protocols in Texas from the Department of Health The preliminary assessments above will provide clearer directions, as well as, epidemiological data from the group affected within the sample of the 25-30 restaurants. The information obtained will be compared with the documented data from the Centers for Diseases Control obtained between 2014 and 2015 regarding the morbidity and mortality due to foodborne illnesses in Texas. 2. Forming Preliminary Standpoint and Future Action At this stage, the process of inspection shall have preliminary information especially from the interviews and decisions will be made on whether to continue with the inspection. If there is evidence that there is continuing public health risk, further inspection will be weighed against local resources and priorities. Other likely reason for the continued inspection will entail: There is a heightened level of public concern about the restaurant Preliminary inspection shows health risks After establishing the preliminary standpoints, subsequent steps will include the following: Descriptive Epidemiological Inspection Stating a case definition Analyzing the data by place, person, time and features Determining the risks Providing evidence-based decision Based on the evidence-based decisions, applying retrospective approaches will help to compare the occurrence of the disease among other restaurants exposed to foodborne diseases against those that were not. 3. Data analysis The process will elicit both qualitative and quantitative data that for interpretation to yield statistically based interpretations. Quantitative data will be analyzed using the statistical package for social sciences (SPSS 20.0) to include CDC surveillance data on the outbreaks of foodborne illnesses, the hospitalizations, and the deaths recorded in Texas2. The results of the quantitative data analysis will provide very useful insights on the incidences of foodborne illnesses, the specific causal agents, and the risk factors that will inform objective restaurant inspections. Results Descriptive statistics The table below outlines the descriptive statistics for foodborne illnesses in Texas during the period 2014 to 2015: Table 1: Descriptive statistics for foodborne illnesses in Texas Descriptive Statistics Months Min Max Mean Std. Deviation Outbreaks 24 0 8 2.79 2.187 Hospitalizations 24 0 204 14.17 42.389 Deaths 24 0 7 .58 1.840 Illnesses 24 0 913 87.79 189.271 Outbreaks of foodborne illnesses in Texas The table below outlines the number of outbreaks of foodborne illnesses in Texas during the period 2014 to 2015: Table 2: Outbreaks of foodborne illnesses in Texas Outbreaks N Valid 24 Missing 0 Mean 2.88 Std. Deviation 2.112 Variance 4.462 Range 8 Minimum 0 Maximum 8 Percentiles 25 1.00 50 2.00 75 4.75 Cumulatively 69 outbreaks of foodborne illnesses were reported in Texas in 2014 and 2015. The outbreaks recorded a mean of 2.79 with a standard deviation of 2.187 for the same period. March 2015 recorded the highest number of outbreaks with a record eight outbreaks of foodborne illnesses whereas no incidences were recorded in December 2014 and September 2015. Graphical presentation of the findings The line histogram below illustrates the pattern of outbreaks for foodborne illnesses in Texas in 2014 and 2015: Figure 1: Outbreaks of foodborne illnesses in Texas Incidence of foodborne illnesses in Texas The table below outlines the incidences of foodborne illnesses in Texas during the period 2014 to 2015: Table 3: Incidence of foodborne illnesses in Texas Illnesses N Valid 24 Missing 0 Mean 87.79 Median 32.00 Mode 0a Std. Deviation 189.271 Variance 35823.563 Range 913 Minimum 0 Maximum 913 Sum 2107 Percentiles 25 5.50 50 32.00 75 64.75 July 2015 recorded the highest number of foodborne illnesses with 913 cases followed by May 2014 during which 301 foodborne illnesses were recorded. During this period, a total of 2107 foodborne illnesses were recorded with a mean of 97.79 and a standard deviation of 189.271 Graphical presentation of the findings The line graph below illustrates the pattern of cases of foodborne illnesses recorded in Texas in 2014 and 2015: Figure 2: Incidence of foodborne illnesses in Texas Hospitalizations due to foodborne illnesses in Texas The table below outlines the number of individuals hospitalized due to foodborne illnesses in Texas during the period 2014 to 2015: Table 3: Hospitalizations due to foodborne illnesses in Texas Hospitalizations N Valid 24 Missing 0 Mean 14.17 Median .50 Mode 0 Std. Deviation 42.389 Variance 1796.841 Range 204 Minimum 0 Maximum 204 Sum 340 Percentiles 25 .00 50 .50 75 6.00 During the period 2014 to 2015, 340 individuals were hospitalized due to foodborne illnesses. 60% of all the hospitalizations in 2014 and 2015 were recorded in July 2015 whereby 204 individuals were hospitalized. On average, there were 14.17 cases of hospitalization during this period with a standard deviation of 42.389. Graphical presentation of the findings The line graph below illustrates the number of hospitalized individuals due to foodborne illnesses in Texas in 2014 and 2015: Figure 3: Hospitalizations due to foodborne illnesses in Texas Deaths due to foodborne illnesses in Texas The table below outlines the number of deaths recorded due to foodborne illnesses in Texas during the period 2014 to 2015: Table 5: Deaths due to foodborne illnesses in Texas Deaths N Valid 24 Missing 0 Mean .58 Median .00 Mode 0 Std. Deviation 1.840 Variance 3.384 Range 7 Minimum 0 Maximum 7 Sum 14 Percentiles 25 .00 50 .00 75 .00 During the 2014 to 2015 period, a total of 14 deaths were recorded due to foodborne illnesses with 50% of them occurring in October 2014 while July 2015 accounted for 42.9% of the deaths. Graphical presentation of the results The line graph below illustrates the pattern of deaths recorded due to foodborne illnesses in Texas in 2014 and 2015: Figure 4: Deaths due to foodborne illnesses in Texas Discussion Interviews with respondents revealed four complaints of food poisoning reported in Texas during the inspections. Further investigations revealed that three of the complaints did not warrant further assessments based on the high demerit scores achieved. Consequently, we implemented impact interventions that entailed educating the consumers and restaurant owners as well as the food handlers on appropriate hygiene measures including effective handwashing practices and single-use gloves while handling some items utilized during various stages of food processing. During the routine inspections, we assessed the temperatures at which the various restaurants maintained their foodstuff particularly the proper hot and cold holding temperatures as well as the reheating temperatures. The inspector established this to be of great concern with many restaurants not meeting the compliance requirements, and this is a potential source of foodborne illnesses. In addition, the assessment also established that majority of the restaurants obtain their TCS food from approved sources. 13, 14. In regards to protection of food items from potential sources of contamination, we established that the food handlers played a major role in ensuring the safety of TCS foods. Part of the interventions included training the food handlers on different aspects of food safety. The amount demonstrated by the persons in charge of TCS foods is insufficient to guarantee food safety. It is very vital that managers of restaurants ensure the adherence to manufacturer’s instructions in regards to the processing of various TCS foods served in their units. The training also emphasized on consumer advisories, which are essential to ensure that consumers of TCS foods are not exposed to substances that could potentially result to debilitation. Insects and rodents within the food holdings contribute to the transmission of foodborne illnesses thus prompting the managers for food restaurants to install measures that rid food stores of these agents. Lack of adequate hygiene measures in some food establishments in Texas including the cleanliness of the physical facilities, the efficacy of the refuse disposal mechanisms, and the cleanliness of the toilets contribute to the incidences of foodborne illnesses. This study highlighted the value of concerted efforts from various industry players including the government, the restaurant owners, and the public in positively contributing to the reduction of foodborne illnesses by complying with the inspection requirements. The Texas Food Establishments Rules (TFER) clearly stipulate the roles for every individual involved in the manufacturing, processing, and distribution of TCS foods in a manner that safeguards the health of the public. The analyzed data reveals glaring discrepancies in the reporting of foodborne illnesses in Texas with several unconfirmed cases of the epidemiological agents 6 . There is a need to harness the policy targeting public disclosure through the integration of social media platforms that provide invaluable data to restaurant inspectors. During the practicum, the inspector inspected thirty restaurants in Texas to assess their compliance with the TFER guidelines. Notably, the majority of the restaurants did not fully comply with the stipulated guidelines regarding the cooling and holding systems. Consequently, the lack of compliance contributes to the high incidence of foodborne illnesses reported in Texas. Routine inspections remain very useful in strengthening compliance to these policies and ensuring that the health of the public is safeguarded at all times. Kang et al. (2013), demonstrated how information from social media platforms could be harnessed to predict potential outbreaks by informing timely inspections with the subsequent institution of remedial measures against potential risks. In a separate study, Harrison et al. (2014), noted that some restaurant managers in New York City only reported outbreaks of foodborne illnesses on their online reviews but not to the Department of Health and Mental Hygiene (DOHMH). On the contrary, these outbreaks were never captured by the reporting agencies thus contributing to unreliable findings of the actual status of the regarding foodborne illnesses. These findings confirmed that the utilization of data obtained from online reviews to identify unreported outbreaks and predict patterns for the illnesses remains very essential3. Coupled with training and supportive supervision activities, routine inspections will enable the identification of gaps in reporting systems and institute corrective measures to predict patterns and mitigate outbreaks in real time. This study outlined the value of training the personnel involved in restaurant inspections including managers and food handlers. This would ensure timely detection of outbreaks as well as rolling out of preventive measures to contain and control outbreaks. Lee et al. (2012), evaluated the utilization of health inspection reports as predictors for training needs. The study established that the type of operation and the inspector had significant implications on the scores achieved during the inspection exercises. The study recommended the standardization of training programs for restaurant inspectors as well as the managers to harmonize the outcomes of the inspection exercises. 13, 14. This investigation unearthed invaluable evidence confirming the importance of restaurant inspections in the prevention of foodborne illnesses. On the contrary, Powell et al. (2012), analyzed inspections and food audits for being insufficient measures in the prevention of foodborne illnesses, the authors explored the limitations with a focus on food processors as key contributors to the outbreaks but often left out during the inspection exercises. Instead, Is argued that development of strong food safety cultures to include risk-based verification steps across the entire food supply system would enormously contribute to the reduction of foodborne illnesses 15,16. According to Gould et al. (2013), there is much work required to prevent foodborne illnesses caused by food handlers who accounted for 64% of the reported outbreaks. They observed that more than half of all the outbreaks relating to foodborne illness arose from restaurants. The authors recommended further strengthening of existing policies in order to ensure individuals charged with food preparation undergo routine health checks and relieved from handling any TCS food in the event they have a suspected illness to prevent transmission of pathogens. 6 In another study in Phoenix, Arizona and Minal (2010), reviewed a prolonged Salmonella outbreak reported in several restaurants. The outbreak was blamed on poor hygienic conditions that led to cross-contamination of food items. The research concluded by emphasizing the importance of routine inspections for high-risk restaurants coupled with measures to reduce contamination of raw products as well as cross-contamination by food handlers at service points. On the contrary, Cruz et al. (2001), assessed the ability to predict outbreaks for foodborne illnesses using restaurant inspections in Miami. The study revealed that the inspections conducted were not sufficient in predicting potential outbreaks for foodborne illnesses and recommended the need to update the inspection practices. 17, 18. Without properly structuring inspection activities, their outcomes may not be sufficient in the prevention of foodborne illnesses. A thorough review of the process of inspection activities is therefore essential to ensure desired outcomes are generated and contribute to the prevention of foodborne illnesses. Indeed when the correct approach is utilized and the right guidelines are followed through the application of the rules governing food establishments in Texas, prevention of foodborne illnesses is a possible outcome. During the practicum, the inspector actively trained food handlers and equipped them with the right knowledge regarding various aspects that contribute to food safety. The application of the right knowledge and skills gained remarkably contributed to safe food practices with the reduction in the reported incidences of foodborne diseases outbreaks. Training food handlers and all persons involved in the preparation, storage and distribution of TCS foods to the public thus safeguarding their health The findings of this study are consistent with a research conducted by Kassa et al. (2010), who evaluated the effect of training and certifying restaurant managers on food safety. The results confirmed that indeed training the managers of restaurants on food safety markedly reduced the incidences of foodborne illness and recorded minimal non-critical violations during the restaurant inspection activities. This knowledge awareness led to a higher compliance rate with prevailing inspection requirements thus translating to early detection of potential outbreaks of foodborne illnesses. 19, 20. Conclusion In the course of the inspection activities, the inspector reviewed the available data on foodborne illnesses from the Centers for Disease Control to inform the findings of this study. Restaurant inspections are very essential in reducing the incidence of foodborne illnesses that contribute to preventable morbidity and mortality in the United States. The routine inspections are useful in identifying gaps that can lead to potential outbreaks, detecting causes for actual outbreaks, and identifying control measures for current outbreaks to prevent further spread. There is also need to build the capacity of inspecting officers, epidemiologists, and restaurant owners through training to improve the outcome of inspection exercises. It will address the gaps evidenced by the data generated from previous inspection exercises that did not provide conclusive data. Recommendations There is need to train all the food handlers in Texas on aspects of food safety and provide a certification for the same. The Department of Health should only issue operating licenses to those restaurants whose employees are certified food handlers. In addition, the food handlers should be subjected to periodic updates on food safety to ensure they remain knowledgeable and competent in promoting food security. The Department of Health should also strive to increase the awareness of the public on detecting and reporting potential outbreaks of foodborne illnesses to the relevant authorities. Further studies Further studies should be conducted on the use of social media reports by food establishments as a means of widening the surveillance scope for foodborne illnesses. References 1. Centers for Disease Control and Prevention. FOOD Tool | CDC. Cent Dis Control. 2016. 2. Bryman A. Social Research Methods. Oxford University Press; 2015. 3. Kang JS, Kuznetsova P, Luca M, Choi Y. Where Not to Eat? Improving Public Policy by Predicting Hygiene Inspections Using Online Reviews. In: EMNLP. Citeseer; 2013:1443–1448. 4. Ameme DK, Alomatu H, Antobre-Boateng A, et al. Outbreak of foodborne gastroenteritis in a senior high school in South-eastern Ghana: a retrospective cohort study. BMC Public Health. 2016;16(1):564. 5. Schaffner DW, Brown LG, Ripley D, et al. Quantitative data analysis to determine best food cooling practices in US restaurants. J Food Prot. 2015;78(4):778–783. 6. Gould LH, Rosenblum I, Nicholas D, Phan Q, Jones TF. Contributing factors in restaurant-associated foodborne disease outbreaks, FoodNet sites, 2006 and 2007. J Food Prot. 2013;76(11):1824–1828. 7. Smith-Simpson S, Schaffner DW. Development of a model to predict growth of Clostridium perfringens in cooked beef during cooling. J Food Prot. 2005;68(2):336–341. 8. Brown LG, Ripley D, Blade H, et al. Restaurant food cooling practices. J Food Prot. 2012;75(12):2172–2178. 9. Bermúdez-Millán A, Pérez-Escamilla R, Damio G, González A, Segura-Pérez S. Food safety knowledge, attitudes, and behaviors among Puerto Rican caretakers living in Hartford, Connecticut. J Food Prot. 2004;67(3):512–516. 10. Ross M, Guzewich J. Evaluation of risks related to microbiological contamination of ready-to-eat food by food preparation workers and the effectiveness of interventions to minimize those risks. FDA White Pap FDA CFSAN. 1999. 11. Baxter P, Jack S. Qualitative case study methodology: Study design and implementation for novice researchers. Qual Rep. 2008;13(4):544–559. 12. Burns H. Visualizing social science research. Maps, methods, and meaning. Int J Res Method Educ. 2012;35(3):328–329. 13. Lee P, Allen K, Daly M. A “Communication and Patient Safety”training programme for all healthcare staff: can it make a difference? BMJ Qual Saf. 2012;21(1):84–88. 14. Murphy KS, DiPietro RB, Kock G, Lee JS. Does mandatory food safety training and certification for restaurant employees improve inspection outcomes? Int J Hosp Manag. 2011;30(1):150–156. 15. Powell DA, Erdozain S, Dodd C, Costa R, Morley K, Chapman BJ. Audits and inspections are never enough: a critique to enhance food safety. Food Control. 2013;30(2):686–691. 16. Wong MR, McKelvey W, Ito K, Schiff C, Jacobson JB, Kass D. Impact of a letter-grade program on restaurant sanitary conditions and diner behavior in New York City. Am J Public Health. 2015;105(3):e81–e87. 17. Cruz MA, Katz DJ, Suarez JA. An assessment of the ability of routine restaurant inspections to predict food-borne outbreaks in Miami-Dade County, Florida. Am J Public Health. 2001;91(5):821. 18. Läikkö-Roto T, Mäkelä S, Lundén J, Heikkilä J, Nevas M. Consistency in inspection processes of food control officials and efficacy of official controls in restaurants in Finland. Food Control. 2015;57:341–350. 19. Kassa H, Silverman GS, Baroudi K. Effect of a manager training and certification program on food safety and hygiene in food service operations. Environ Health Insights. 2010;4:13. 20. Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM, others. Foodborne illness acquired in the United States—unspecified agents. Emerg Infect Dis. 2011;17(1):16–22.  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