NEHA June 2024 Journal of Environmental Health

The June 2024 issue of the Journal of Environmental Health (Volume 86, Number 10), published by the National Environmental Health Association.

JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 86, No. 10 June 2024

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Published by the National Environmental Health Association

Standard Methods for the Examination of Dairy Products, 18th edition Edited by Jeffrey L. Kornacki, PhD, Elliot T. Ryser, PhD, and Cynthia M. Mangione; Managing Editor: H. Michael Wehr, PhD Standard Methods for the Examination of Dairy Products is a widely-recognized source of methods to assess the safety and quality of dairy products. It is an overview of microbiological, chemical and physical methods for analyzing milk and dairy products, designed for use by regulatory, industry and commercial laboratories. As with earlier editions, the 18th edition of Standard Methods for the Examination of Dairy Products:

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JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 86, No. 10 June 2024

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ABOUT THE COVER

Foodborne disease is a substantial public health prob- lem. Restaurant inspections are the primary way health departments can verify that food safety practices and policies are being

Information Sharing Preferences, Inspection Perceptions, and Employee Illness Behavior: A Survey of More Than 1,500 Minnesota Food Workers ................................8

Special Report: Development, Evaluation, and Long-Term Outcomes of Environmental Health and Land Reuse Training—Part 1: Developing Environmental Health and Land Reuse Trainings for the Environmental Health Workforce and Their Community Partners ............ 16

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properly implemented, as well as serve as an opportunity for inspectors to build relation- ships with food workers. In this issue’s cover article, the Minnesota Department of Health surveyed workers in food and beverage service facilities to better understand their needs and behaviors. Specifically, the survey aimed to 1) assess how food workers want to receive food safety information, 2) better understand how they perceive inspections and their interactions with health inspectors, and 3) better under- stand employee illness reporting behaviors. See page 8. Cover images © iStockphoto: appleuzr, gentle studio, Kuliperko

Special Report: Performance Indicators Corresponding to the Critical Competencies in Children’s Environmental Health ............................................................................................. 24

Building Capacity: A Vision for Inspector Routing to Build Capacity .......................................... 30

Direct From ATSDR: PFAS Information for Clinicians From ATSDR .......................................... 32

Practitioner’s Tool Kit: Disinfectant Versus Sanitizer .................................................................. 36

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Spotlight on NEHA Member Resources .................................................................................... 39

ADVERTISERS INDEX

Environmental Health Calendar ...............................................................................................40

American Public Health Association (APHA)........ 2 CDP, Inc.................................................................. 7 EHAC-Accredited Programs ................................. 29 EHLR Certificate Program.................................... 22 HS GovTech.......................................................... 48 JEH Advertising ....................................................35 NEHA CP-FS Credential ......................................38 NEHA Credentials ................................................ 40 NEHA Endowment Foundation Donors .............. 23 NEHA Membership .......................................... 4, 15 NEHA REHS/RS Study Guide............................... 35 NEHA/AAS Scholarship Fund Donors ................... 5

Resource Corner........................................................................................................................ 41

YOUR ASSOCIATION

President’s Message: The Future Is Bright ............................................................................................... 6

Special Listing ........................................................................................................................... 42

NEHA News .............................................................................................................................. 44

NEHA 2024 AEC....................................................................................................................... 46

June 2024 • Journal of Environmental Health

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in the next Journal of Environmental Health don’t miss  e*o+in. #rainin. Nee+8 $8in. !elevan*e an+ E=6o8ure to +entif> #rainin. Nee+8 in the !etail oo+ !e.ulator> &or1for*e  E=6o8ure to ontaminant8 urin. *tive #ran86ort an+ the Effe*t on Health arameter8  "urve> of #i*1 "6e*ie8 in i88ouri

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An open access journal published monthly (except bimonthly in January/ February and July/August) by the National Environmental Health Association (NEHA), 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 802-2200; Internet: www.neha.org. E-mail: jeh@neha.org. Volume 86, Number 10. Yearly print subscription rates: $160 (U.S.) and $200 (international). Single print copies: $15, if available. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2024, NEHA (no refunds). Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. Advertising rates available at www.neha.org/jeh. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). Full electronic issues from present to 2012 available at www.neha.org/jeh. All technical manuscripts submitted for publication are subject to peer review. Visit www.neha.org/jeh for submission guidelines and instructions for authors. To submit a manuscript, visit https://jeh.msubmit.net. Direct all questions to jeh@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910.

Journal of Environmental Health (ISSN 0022-0892)

n 6en **e88 Journal

Kristen Ruby-Cisneros, ana.in. E+itor Ellen Kuwana, MS, o6> E+itor Hughes design|communications, e8i.nro+u*tion Cognition Studio, over rt<or1 Soni Fink, +verti8in. or a+verti8in. *all 0 80221 Technical Editors William A. Adler, MPH, RS !etire+ inne8ota e6artment of Health, !o*he8ter, N Gary Erbeck, MPH

!etire+ ount> of "an ie.o e6artment of Environmental Health, "an ie.o, Thomas H. Hatfield, DrPH, REHS, DAAS alifornia "tate $niver8it>, Northri+.e, Dhitinut Ratnapradipa, PhD, MCHES rei.hton $niver8it>, maha, NE

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Volume 86 • Num)er 10

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Mario Seminara Saurabh Rajan Shirodkar Stephanie Shopbell Zia Siddiqi Tom Sidebottom Puneet Sikand Traci E. Slowinski Christopher J. Smith Derrick Smith Kimberly J. Smith Shane M. Smith Aileen Solaita Dorothy A. Soranno James M. Speckhart Christan Stager Daisy Steiner Rebecca Stephany Thomas Sutter M.L. Tanner Jacqueline Taylor Ned Therien Dennis Torrey Samantha Totoni Charles D. Treser Randall Trox Keith Uccello Rebecca L. Uzarski Gail P. Vail Linda Van Houten Kennon J. Vann-Kelley Gratiela D. Vasilica Jenny Villatoro Leon F. Vinci Jacqueline Walton Jessica Walzer Robert B. Washam Manar Wassel Carolyn Watson Michael Weakley April L. Wendling James M. White Dawn Whiting Stacy L. Williamson Diana M. Wilson Erika Woods Ronald Young

Katharine Mooney Wendell A. Moore Lisa Maggie M. Morehouse Hector Morfin George A. Morris Daniel C. Morrison Christine Moser-Fink Myrna Motto Victoria A. Murray Dwight T. Nakao John A. Nakashima Johany D. Negron Bird Lee Newman

Scott E. Holmes Jamison S. Honeycutt Trudy Hyde Indiana Environmental Health Association Maria Ingram Renae Irons Kyle Johnsen Nikia Jones Gregory D. Kearney Dennis Keith Nadia T. Kendall

Jessica Einig Amer El-Ahraf

Samuel M. Aboagye Tunde M. Akinmoladun American Academy of Sanitarians Christopher B. Adams

William B. Emminger Alicia Enriquez Collins Annette Eshelby Jaime Estes Bruce M. Etchison Suzanne Fajgier Wendy L. Fanaselle Doug Farquhar Vincent J. Fasone Karl D. Feldmann Julie Fernandez Samantha P. Fontenelle Debra Freeman Lauren Fuertes Francisca Funke Heather Gallant Jeanne M. Galloway Desire Garcia Gnandi Gbandi Leah F. Geier

Erick Aguilar Mary A. Allen

Angela Anandappa Stephanie Aragon James J. Balsamo, Jr. Dick Darrel L. Baluscang Gina Bare Darryl Barnett Tanner Bell Robert Bialas Rachelle Blackham David Blossom Eric Bowles Christopher Boyles Freda W. Bredy Bryan W. Brooks D. Gary Brown Lawrence A. Brown Wendy K. Brown-Arnold Glenn W. Bryant Thomas J. Butts Maurice Bynum Blanca Caballero Kim Carlton Deborah Carpenter Ann M. Carroll Aaron Chavez Isaac Cisneros Renee Clark Richard W. Clark Brian K. Collins Alan M. Croft William Crump Mark Cummins Bonnie Czander Kenneth C. Danielson Daniel de la Rosa Kristen deBraga Beata Dewitt Kimberly M. Dillion Jennifer Dobson James M. Dodd Theresa Dunkley-Verhage

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Roy Kroeger John W. Lam Justice B. Lambon Bobbi Lauzon Zachary Lee Brian Lefferts Philip Leger Nichole D. Lemin Matthew A. Lindsey Martin Little

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June 2024 • Journal of Environmental Health

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Open Access

 PRESIDENT’S MESSAGE

The Future Is Bright

Tom Butts, MSc, REHS

I cannot believe this column is my final one as president of the National Environ- mental Health Association (NEHA). First I will share how privileged and honored I feel to have served as NEHA president. It has been an interesting year and the to-do list remains long as I write this column. I wish to thank you, our members, for allowing me to serve this past year as your president. I have tried to be a good steward of NEHA by promoting environmental public health’s large local role, supporting the great NEHA sta, and advocating for evidence- based activities. It has been a humbling expe- rience and another learning opportunity. I also had the opportunity to visit many of our a liates, exchange ideas, and learn from you. I would be remiss not to recognize our NEHA sta, with a workload that challenges their capacity regularly, and Executive Direc- tor Dr. David Dyjack, for the outstanding jobs they have done these past 4 years where I have been a close observer. This year we took a new spin on Hill Day! We strived to increase awareness of environmental health and local issues in the U.S. Congress. We endeavored to be customer-oriented with state, local, tribal, and territorial support from the NEHA-FDA Retail Flexible Funding Model (RFFM) Grant Program. We have also worked in a range of ways to support the global footprint and knowledge base of environmental health. Our Board of Directors has also stepped up to meet many challenges. Past and future presidents and active regional vice-presidents visited many of our a liates and worked behind the scenes on numerous committees and projects. The last year has been a plea- sure to work with an engaged Board of Direc-

I asked Chat GPT the following question: “What is environmental public health and why is it important?” Here is the response: “Environmental public health is a multi- disciplinary field that focuses on the study and management of environmental factors that can potentially aect human health. It encompasses a wide range of topics includ- ing air and water quality, food safety, waste management, toxic substances, and climate change. The primary goal of environmental public health is to prevent and control dis- eases, injuries, and health conditions that result from the interaction of people with their environment. It is important for several reasons: • Prevents disease and protects health: By identifying and mitigating environmen- tal risks, such as pollution or hazardous waste, environmental public health eorts help prevent a range of diseases and health conditions, including respiratory illnesses, waterborne diseases, and cancers linked to environmental factors. • Promotes healthy environments: It encour- ages the creation and maintenance of healthy environments for living, working, and recreation. This includes ensuring access to clean water and air, safe food sup- plies, and healthy workplaces. • Addresses climate change: Environmental public health looks at the impacts of climate change on human health and develops strat- egies to adapt to and mitigate these impacts. This includes preparing for more frequent and severe weather events, such as hurri- canes and heat waves, and addressing the spread of diseases facilitated by changing temperatures and precipitation patterns.

What I see are dedicated, enthusiastic people who are ready to apply their

new and existing skills to whatever challenge arises.

tors and sta who are excited and dedicated to assuring that our organization is doing well and doing good things. As specialists or generalists from local gov- ernment, state government, federal govern- ment, the uniformed services, industry, and academia, we all have important roles—be they large or small—to work to assure safe food, safe drinking water, cleaner air, safe and eec- tive vector control, healthy housing, and much more. I have met many engaged and excited new peers in the workforce who daily rise up to meet the needs of the communities we serve. We are faced with new challenges—artifi- cial intelligence (AI), social media, the politi- cization of science, per- and polyfluoroalkyl substances (PFAS), and electric vehicle fires. As I have talked with environmental public health professionals across the country, I con- tinue to hear about the unique approaches each local environmental health agency takes to provide community-appropriate services. What I see are dedicated, enthusiastic people who are ready to apply their new and existing skills to whatever challenge arises.

Volume 86 • Num)er 10

• Supports sustainable development: By advocating for practices and policies that protect the environment and human health, environmental public health is integral to sustainable development. This includes promoting the sustainable use of natural resources, reducing pollution and waste, and ensuring that development activities do not harm human health. • Informs policy and regulation: Research and activities within environmental public health inform the development of policies and regulations designed to protect public health and the environment. This includes legislation related to air and water quality, chemical safety, and the management of hazardous substances. • Equity and justice: Environmental public health eorts often focus on addressing disparities in health outcomes related to environmental factors. This includes work-

ing to ensure that all communities, includ- ing those that are historically marginal- ized or economically disadvantaged, have access to a healthy environment. Overall, environmental public health is crucial for maintaining and improving the health and well-being of populations by addressing the complex interplay between environmental factors and human health.” Now the opportunity is to ensure that our community leaders, funders, and neighbors understand what we do, too. I will close with a quote from Edward Abbey, not an environmental health legend but an author and essayist. You might, however, find some useful advice as we all must balance work and personal lives as we face sometimes frus- trating and dicult situations. Abbey wrote: “One final paragraph of advice: Do not burn yourself out. Be as I am—a reluc-

tant enthusiast…a part-time crusader, a half-hearted fanatic. Save the other half of yourselves and your lives for pleasure and adventure. It is not enough to fight for the land; it is even more important to enjoy it. While you can. While it’s still there. So get out there and hunt and fish and mess around with your friends, ram- ble out yonder and explore the forests, climb the mountains, bag the peaks, run the rivers, breathe deep of that yet sweet and lucid air, sit quietly for a while and contemplate the precious stillness, the lovely, mysterious, and awesome space. Enjoy yourselves, keep your brain in your head and your head firmly attached to the body, the body active and alive…”

tbutts@neha.org

You can use our new toolkit to adopt the updated Body Art Model Code (BAMC) in your jurisdiction. The toolkit includes everything you need to help convince decision-makers and industry to adopt the updated code. Find the updated BAMC and adoption toolkit at www.neha.org/body-art-model-code.

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Information Sharing Preferences, Inspection Perceptions, and Employee Illness Behavior: A Survey of More Than 1,500 Minnesota Food Workers

Nicole D. Hedeen, MS, RS Environmental Health Division, Minnesota Department of Health

50% of confirmed foodborne outbreaks are caused by norovirus (Minnesota Department of Health, unpublished data). To prevent nor- ovirus outbreaks, the Minnesota Food Code has several provisions that target foodborne illness prevention, including requirements for food workers to report symptoms of vom- iting and/or diarrhea to the person-in-charge (PIC), for the PIC to record employee symp- toms of vomiting or diarrhea, to exclude ill employees for at least 24 hr after they recover from vomiting or diarrhea, and for the estab- lishment to report any complaints of patron illness to the regulatory authority. Although these measures are outlined in the Minnesota Food Code, norovirus remains the leading cause of foodborne outbreaks. Restaurant inspections are the primary way health departments can verify that food safety practices and policies are being properly implemented (Barnes et al., 2022) . Inspections are also an opportunity for inspectors to build a relationship with opera- tors. The one-on-one interactions that occur during inspections are often used to help educate food workers about the requirements of the food code. The dissemination of food safety information through resources such as videos, fact sheets, trainings, and inspections are also a crucial way that health departments provide education and training to food work- ers. In Minnesota, and likely nationwide, relationships between restaurant operators and regulatory agencies became strained dur- ing the COVID-19 pandemic due to health departments having to enforce restaurant closure orders and ensure compliance with other COVID-19 prevention measures. As a result, many regulatory agencies had to put inspections and food safety outreach activi- ties on hold due to the pandemic.

)8tra*t In February 2022, the Food, Pools, and Lodging Ser- vices Section at the Minnesota Department of Health sent out a 29-question, anonymous electronic survey to food workers across Minnesota. The goals of the survey were to 1) identify the most eective methods for distributing food safety information to operators; 2) understand operator behaviors per- taining to illness reporting and other Minnesota-specific code requirements; and 3) understand how operators view health department inspections, their perceptions of the inspection process, and interactions with their inspector. A total of 1,535 food workers participated in the survey. The feedback and findings from the survey will be used to inform how the Minnesota Depart- ment of Health conducts future training and outreach and will help identify gaps in food safety training. Keywords: food worker survey, food safety preferences, food worker beliefs, inspection perceptions, illness behaviors

Introduction Foodborne disease is a substantial public health problem. The Centers for Disease Con- trol and Prevention (CDC, 2018) estimates that approximately 48 million people get sick, 128,000 are hospitalized, and 3,000 die from foodborne disease annually in the U.S. Noro- virus is the most common cause of foodborne illness and foodborne outbreaks; ill food work- ers cause approximately 70% of the reported foodborne norovirus outbreaks in the U.S. annually (CDC, 2019a; White et al., 2022). Restaurants are the most common setting for foodborne outbreaks and account for approxi- mately 60% of such outbreaks (CDC, 2019b). The Food and Drug Administration (U.S. Department of Health and Human Services, 2017) publishes the Food Code that is used by state, local, and federal regulators as a model

for best practices to ensure food is handled safely in retail settings to prevent foodborne illness. Minnesota adopted the 2013 FDA Food Code that went into eect in the state on January 1, 2019, as the Minnesota Food Code. All restaurant inspections completed in Min- nesota are based on the requirements within the current food code (Minnesota Department of Health, 2019). The Food, Pools, and Lodg- ing Services Section at the Minnesota Depart- ment of Health (MDH) inspects approximately 14,000 food, pool, and lodging establishments and has delegation agreements with 28 local health departments, which also inspect a combined total of 14,000 additional establish- ments across Minnesota. Similar to the national data, norovirus is the leading cause of foodborne illness out- breaks in Minnesota, where approximately

Volume 86 • Num)er 10

Although the sharing of food safety resources and interactions during health inspections are important, MDH has never surveyed food workers to evaluate and under- stand their preferences for receiving food safety information and how they perceive the current inspection process. We also were interested in understanding food worker behaviors pertain- ing to illness reporting and other MDH-specific requirements. Therefore, we created a survey to better understand the needs and behaviors of food workers related to these processes. Methods Sta from the Partnership and Workforce Development Unit within MDH surveyed workers in food and beverage service facili- ties (e.g., restaurants, delicatessens, coee shops, bars) to 1) assess how they want to receive food safety information; 2) better understand how they perceive inspections and their interactions with health inspectors; and 3) better understand employee illness reporting behaviors. The survey instrument was created in Microsoft Forms and consisted of 29 ques- tions, which were a mix of open-ended, Lik- ert scale, and rating questions (Supplemental Survey File, www.neha.org/jeh-supplemen tals). The survey was presented in English, took an average of 7.5 min to complete, and was piloted internally prior to launch. The survey link was active for 33 days beginning on February 21, 2022, and was distributed to subscribers of the GovDe- livery email system of the Partnership and Workforce Development Unit (sent out to approximately 30,000 email subscribers) that includes food and beverage service facility operators and food workers in Minnesota. The survey was also advertised on MDH Facebook and Twitter accounts. We reviewed link clicks within the first 48 hr of the survey being sent out to deter- mine how the link was being accessed. There were 714 unique clicks via our GovDelivery system, 343 link clicks via Facebook, and 20 engagements (similar to link clicks) via Twit- ter. Sending the survey out via our GovDe- livery system appeared to yield the highest response for participation. The survey announcement included infor- mation on the purpose of the survey, the vol- untary nature of the survey, the anonymity of the survey, and how to request further infor-

mation. Individuals who wanted to partici- pate could access the survey questions via a link within the announcement. We provided a second GovDelivery reminder for survey participation 1 week before the survey closed on March 25, 2022. Descriptive and qualitative data analyses on the survey responses were performed with Microsoft Excel version 2208. Results A total of 1,659 food workers responded to the survey. Of those, 1,535 (93%) said they were individuals who worked in a food or beverage service setting and were able to complete the entire survey. The other 124 respondents reported that they did not work in a food or beverage service setting, and the survey subsequently ended. Survey Respondent Demographics A majority of survey respondents reported that their age was >51 years (46%), their primary work duty was management (66%), their primary language was English (96%), and they had worked in food service for >15 years (58%). Moreover, 88% of respondents said they had been a certified food protec- tion manager (CFPM) at some point in their career, and of those, 92% still had a valid CFPM certificate (Table 1). Food Safety Information Preferences The most common responses for where survey respondents currently get their food safety information were a CFPM course such as ServSafe or Prometric (72%), classes and trainings (60%), conversations with a health inspector (60%), and the MDH web- site (40%). Less common responses included social media, magazines, and blogs (Table 2). When respondents were asked, “What is your preferred method to receive informa- tion,” the most common responses were email such as newsletters and updates (63%), online trainings and presentations (50%), in-person trainings or presentations (40%), and conversations with their health inspector (33%). Less common responses were super- visor or colleagues, web content, mail flyers, and social media. When asked, “What food safety topics do you wish you had more information on,” the answers varied, with many respondents want- ing more information on food code require-

ments (47%), food recalls or consumer warn- ings (41%), and general food safety (41%). Additionally, respondents selected food safety fact sheets (50%) and more communication from the health department about require- ments and food code updates (45%) as the top choices when asked, “What would make you more eective in ensuring safe food handling practices are followed in your restaurant?” We separated out respondents who reported that they have never been a CFPM ( n = 178) from respondents who have been a CFPM ( n = 1,357). Both respondent groups reported food code requirements and general food safety as the top responses when asked, “What food safety topics do you wish you had more infor- mation on?” Respondents who had never been a CFPM were slightly less interested in receiv- ing information on food recalls or consumer warnings than respondents who had been a CFPM (33% versus 42%). Furthermore, respondents who had never been a CFPM reported, “Paid sick leave so I don’t work while ill” (54%) as the top choice for what would make them more eective in ensuring safe food handling practices are followed in their restaurant. Respondents who had been a CFPM chose food safety fact sheets (51%) and more communication from the health department about requirements and food code updates (46%) as the top responses for what would make them more eective, but paid sick leave was selected only 28% of the time. When looking at the dierences in receipt of food safety information between respondents who were or were not CFPMs, the most com- mon way non-CFPMs are receiving food safety information is through their supervisor (59%) and their coworkers (35%); furthermore, their preferred method to receive food safety infor- mation is through their supervisor (47%) and online trainings (45%). Responses from indi- viduals who had been a CFPM were consistent with the findings of the entire group. Perception of Inspections Survey respondents were asked, “In gen- eral, how beneficial are health department inspections?” The majority (89%) of respon- dents said inspections were very beneficial (48%) or somewhat beneficial (41%). Addi- tionally, 70% of respondents would not want to change anything about their inspection process, while 17% said they would like to change something (Table 3). We then asked

June 2024 • Journal of Environmental Health

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the respondents who said yes, “What would you change about your inspection pro- cess?” This question was open-ended and responses varied, but some of the more com- mon themes included having inspections scheduled, making inspections a more con- sultative and educational experience, having better consistency among jurisdictions and inspectors, and having more frequent and thorough inspections. We also found that three quarters of sur- vey respondents were very satisfied (57%) or somewhat satisfied (18%) with their interactions with the health inspector. We asked, “How has your relationship changed with your health inspector over the last 2 years due to COVID-19?” Most respon- dents said the relationship has not changed (76%), while 11% said the relationship has improved and 4% said the relationship has worsened. When asked to describe how their relationship has changed over the last 2 years, the responses varied from reaching out and asking their health inspector more questions to not seeing their inspector at all during the pandemic. One respondent shared, “Haven’t seen them at all (inspector). Zero feedback, zero interac- tion, zero answers to questions in messages I’ve left on voicemail or in emails.” Furthermore, another respondent mentioned that “health inspections seem to be more outcome-based rather than punitive. Much more positive interaction and helpful ideas/information.”

TABLE 1

Demographic Information From a Survey of Minnesota Food Workers ( N = 1,535)

Question

Which category best describes your age? 15–20 years

1 9

21–30 years 31–40 years 41–50 years

134 303 370 706

20 24 46 66 43 40 27 23 18

≥51years

What are your primary work duties at this job? (Check all that apply.) Management

1,013

Food preparation

663 618 422 352 278

Cooking

Front of the house service

Dishwashing

Bartending/coffee service

What is your primary language? English

1,473

Spanish

2 0 0 0 1 0

Chinese (any dialect)

4 4 3

Vietnamese

Hmong

I prefer not to answer

Other

How many years have you worked in food service? <1 year

1–5 years

187 243 198 891

12 16 13 58

Employee Illness Practices and Policies

6–10 years 11–15 years

To assess illness reporting, we asked survey respondents if they had been sick with vom- iting or diarrhea in the past 3 months: 86% said no, 13% said yes, and 1% were unsure (Table 4). We asked those respondents who reported being sick, “Did you tell your super- visor that you were experiencing vomiting or diarrhea before reporting to work?” Of the respondents, 80% said yes and 20% said no (Figure 1). For respondents who reported not telling their supervisor, the main reasons were because the food worker did not want to lose their shift (46%) and that they were worried there would be consequences from management (32%). We then asked all respondents, “Does your restaurant management require employees to report when they are sick with vomiting

>15 years

Have you ever been a certified food protection manager? Yes

1,357

88 12

178

If yes, is your certification still valid? ( n = 1,357) Yes

1,242

115

or diarrhea?” Of the respondents, 80% said yes, 16% said no, and 4% were unsure. We then asked, “If an employee comes into work while sick with vomiting or diarrhea, how does management respond?” Most respon- dents (88%) said management would send the worker home and 4% said management would do nothing.

Furthermore, 75% of survey respondents said management maintained an illness log to record employee illness. For the 11% who said that management did not maintain an ill- ness log, the reasons varied, with food work- ers not knowing why management did not maintain a log (35%) and being unaware of a log requirement (21%).

Volume 86 • Num)er 10

Lastly, we asked, “What would you do if a customer called and said they became sick after eating at your restaurant?” Survey respondents could select multiple answers. The top responses were to notify manage- ment (79%) and to take down the name and number of the caller (77%). In contrast, seven respondents said management would do nothing. Discussion Most of the respondents to our survey were managers who have worked in the food ser- vice industry for a number of years. Therefore, it makes sense that many respondents were current CFPMs and reported receiving food safety information through a CFPM course or other types of classes and trainings. Becom- ing a CFPM means the individual has passed an exam, often after formal training on food safety and foodborne outbreak prevention. Numerous research studies conducted by the CDC Environmental Health Specialist Network (EHS-Net) have shown that restau- rants with a CFPM have better food safety practices and are less likely to be linked with outbreaks (Brown et al., 2014; Clayton et al., 2015; Hedberg et al., 2006; Kramer et al., 2023). For workers who had never been a CFPM, they reported receiving food safety information primarily through supervisors and coworkers. Consequently, CFPMs should continue to use their food safety knowledge to train other sta throughout the facility. Food workers preferred to receive food safety information through email (e.g., news- letters, updates) or online trainings. Our findings are supported by research that shows an upward trend in the number of people who seek online learning and training oppor- tunities (Wood, 2022). The COVID-19 pan- demic likely furthered this shift, with work- ers in varied fields adopting remote work and online learning. In contrast, the use of web content, mail, or social media to distribute food safety informa- tion was less popular. For CFPMs specifically, receiving food safety information through a supervisor or colleague was a less popular choice. Non-CFPMs, however, preferred to receive food safety information through their supervisor in addition to online trainings. Food code requirements, food recalls and con- sumer warnings, and general food safety were all desired topics for future trainings.

TABLE 2

Survey Feedback on How Minnesota Food Workers Want to Receive Food Safety Information ( N = 1,535)

Question

Where do you get your food safety information from? Certified food protection manager course

1,105

72 60 60 40 29 28 26 14

Classes and trainings

919 914 621 451 428 404 217 124 113

Health inspector

Health department website

Websites

Electronic newsletters

Supervisor Coworkers Social media Magazines

8 7 2 3 2

Blogs

31 48 36

I don’t receive food safety information

Other

What is your preferred method to receive food safety information? Email (e.g., newsletters, updates)

965 764 613 508 279 240 148

63 50 40 33 18 16 10

Online trainings or presentations In-person trainings or presentations Conversations with health inspectors

My supervisor or colleagues

Web content (e.g., blogs, websites)

Mail flyers

Social media

58 14

4 1

Other

What food safety topics do you wish you had more information on? Food code requirements

716 633 633 605 501 376

47 41 41 39 33 24

Food recalls or consumer warnings

General food safety

Food safety for new food trends Equipment requirements Foodborne illness prevention

Other 5 What would make you more effective in ensuring safe food handling practices are followed in your restaurant? Food safety fact sheets 766 50 More communication from the health department about food code updates 690 45 Paid sick leave so I don’t work while ill 478 31 Food safety videos 383 25 Additional training provided by the health department 330 21 Additional training provided by management 304 20 82

Note. Respondents could select multiple answers for each of these questions.

June 2024 • Journal of Environmental Health

ADVANCEMENT OF THE SCIENCE

These findings can inform eorts by health departments to provide eective food safety messaging to food workers. Restaurant own- ers and managers can also use these findings when training food workers. Creating a plan on how sta are trained, who conducts the training (e.g., supervisor, CFPM), frequency of trainings, and what topics are covered will ensure that all food workers receive adequate food safety information. Food worker perceptions of inspection and relationships with inspectors were over- whelmingly positive. These findings were contrary to research done in New Zealand and Australia, which found that individu- als who work in the food industry often had distrust for regulatory sta and believed that regulations were based on larger political agendas (Meyer et al., 2017). Respondents to our survey reported that inspections were beneficial, and the majority of food workers would not change the cur- rent process. Conversations with inspectors were the second most common method by which food workers are receiving food safety information, and a top response in how work- ers preferred to receive food safety informa- tion. Inspections are designed to capture the current food safety practices and policies in place at an establishment. Many inspectors, however, go beyond enforcing the food code by providing educa- tion and training to food workers during an inspection. Cultivating relationships with food workers by being available and will- ing to answer questions—without repercus- sions such as a written citation—is extremely important in developing trust between regu- lators and food workers (Meyer et al., 2017). Respondents who reported that they would like to make a change to the inspection pro- cess mentioned several times having sched- uled and/or announced inspections and bet- ter consistency among inspectors and across agencies (i.e., local versus state). For the most part, regulatory agencies across Minnesota conduct unannounced inspections; however, one local agency within Minnesota found that when inspections were scheduled, fewer violations occurred in two categories: 1) demonstration of knowledge by the PIC and 2) prevention of cross-contamination (Reske et al., 2007). Additional research to exam- ine the benefits of scheduled inspections is warranted. The need for consistency across

TABLE 3

Perceptions of the Inspection Process From Minnesota Food Workers ( N = 1,535)

Question

In general, how beneficial are health department inspections? Very beneficial

736 634

48 41

Somewhat beneficial Not at all beneficial

83 82

Unsure 5 Is there anything you would want to change about your inspection process by the health department? Yes 265 17 No 1,079 70 I’m not involved in health inspections 191 12 Please rate your overall satisfaction of interactions with your inspector. Very satisfied 880 57 Somewhat satisfied 280 18 Neither satisfied nor dissatisfied 176 12 Somewhat dissatisfied 31 2 Very dissatisfied 14 1 I don’t interact with my inspector 154 10

agencies and among inspectors is extremely important, and MDH and our delegated agen- cies work to ensure inspections are standard- ized among inspectors and across agencies. For the most part, respondents reported that relationships between food workers and inspectors did not change due to the COVID- 19 pandemic, and there were more reports of relationships improving rather than worsen- ing. During the pandemic, state regulations required restaurants to close for a period of time; they were then allowed only to open for take-out service for a number of months, under additional precautionary require- ments. Inspectors were required to enforce these orders; anecdotal reports indicate that some inspectors were harassed during their enforcement visits. Our findings are posi- tive, as they suggest that, overall, food work- ers did not feel that their relationships with their health inspectors had changed because of the pandemic. Our findings identified several gaps when it comes to employee illness reporting behav- iors, though. There is a substantial portion of food workers who do not report vomiting or diarrhea to management, mainly because they do not want to lose their shift and/or are

concerned about consequences from man- agement. These findings are consistent with other research that shows that the reasons workers work while sick are complex and multifactorial (Carpenter et al., 2013), and contextual factors need to be addressed to create change in food worker behavior (Year- gin et al., 2021). Additionally, social or economic pres- sures such as not wanting to leave cowork- ers short-staed or concerns of losing a job contribute to employees working while ill (Carpenter et al., 2013). With norovirus being the most common cause of outbreaks in food establishments and ill workers being the most cited contributing factor (Moritz et al., 2023), restaurant management needs to take an active role in creating a culture of food safety that encourages employees to stay home when they are sick (Kramer et al., 2023; McFarland et al., 2019). Having a written employee illness plan, training work- ers on what is required of them regarding ill- ness reporting and to stay home while sick, oering paid sick leave, letting sta make up shifts, and cross-training sta could allevi- ate social and economic pressures associated with calling out sick (Moritz et al., 2023).

Volume 86 • Num)er 10

Our survey identified that non-CFPM respondents had a great desire for paid sick leave and listed it as the top response for what would make them more eective in ensuring that safe food handling practices are followed in their restaurant. Conversely, only a low proportion of CFPM respondents chose paid sick leave as a response to the same question. It might be that many CFPMs are managers and therefore themselves have health benefits such as paid sick leave. Or it might be that CFPMs are salaried employees. Future research should be conducted to determine the reasons for the dierence in reporting between CFPMs and non-CFPMs with regard to the perceived potential eec- tiveness of paid sick leave, how paid sick leave aects reporting behaviors for worker illness, and dierences between access to paid sick leave between CFPMs and non-CFPMs. When asked if management maintains an employee illness log, 25% of respondents were unsure or said no. Moreover, only 42% of respondents said they would reach out to their health inspector if they received a customer complaint of illness. We need to continue eorts to communicate the utility of tracking and recording employee symp- toms of vomiting or diarrhea. We also need to emphasize the utility of restaurants report- ing patron complaints to the health depart- ment—both of which are requirements in the Minnesota Food Code. Recording and tracking employee symp- toms and reporting patron complaints of ill- ness can help the PIC to a) identify if an out- break is occurring and b) put interventions in place (e.g., excluding workers, increased handwashing, cleaning and sanitizing) to stop illness transmission. Most of the survey respondents were managers with years of experience who were trained in food safety and food code requirements, so the gaps in employee illness reporting are likely more extensive than reported here. Thus, future research should evaluate how to best address these deficiencies. There were some limitations to this study. The study is representative of Minnesota food workers only. With most of the respon- dents being managers, it is possible that the summary responses do not reflect the actual beliefs and practices of the entire food worker population in Minnesota. Additionally, we do not know where the respondents were located

TABLE 4

Reported Employee Illness Behaviors by Minnesota Food Workers ( N = 1,535)

Question

In the past 3 months, have you been sick with vomiting or diarrhea? Yes

201

13 86

1,322

Unsure 1 Did you tell your supervisor that you were experiencing vomiting or diarrhea before reporting to work? ( n = 201) Yes 160 80 No 41 20 Why didn’t you tell your supervisor that you were sick with vomiting or diarrhea? (n = 41) * I didn’t want to lose my shift 19 46 I was worried there would be consequences from management 13 32 I wasn’t working the days I was sick 10 24 Other 10 24 I wasn’t contagious 6 15 I felt it was too personal 2 5 Does your restaurant management require employees to report when they are sick with vomiting or diarrhea? Yes 1,230 80 No 242 16 Unsure 63 4 If an employee comes in to work while sick with vomiting or diarrhea, how does management respond? * Send worker home 1,345 88 Do nothing 65 4 Unsure 52 3 Put worker in a nonfood area 16 1 Assign worker to other activities 13 1 Other 44 3 Does management at your restaurant maintain an illness log to record employee illness? Yes 1,147 75 No 170 11 Unsure 218 14 Why doesn’t management maintain an illness log to record employee illness? ( n = 170) * Unsure 60 35 Unaware of log requirement 36 21 Management is aware of the log requirement, but there are too many other things to keep track of 30 18 Management has a log but doesn’t maintain it 28 16 Other 26 15 What would you do if a customer called and said they became sick after eating at your restaurant? * Notify management 1,206 79 Take down the name and number of the caller 1,189 77 Investigate internally 750 49 Notify health inspector 641 42 Contact restaurant corporate office 214 14 Do nothing with it 7 0 Other 76 5 Unsure 29 2 * Survey respondents could select multiple answers for these questions. 12

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