Letters to the editor.

Dear Editor:

Regarding the featured article in the March 2005 Journal of Environmental Health titled "Impact of Restaurant Hygiene Grade Cards on Foodborne-Disease Hospitalizations in Los Angeles County."

I would like to compliment the authors of this article for their insightful use of the grading system in the prevention of disease. The article points out that the implementation of the public disclosure and posting of grades in the county's grading system has statistical impact on the reduction of foodborne-illness (FBI) hospitalizations. There is no doubt that the system works and that the public awareness of the scoring and the economic incentives for the food facility operators resulting from the grading system have likely intervened in the FBI process.

I believe, however, that there is also another factor affecting FBI results. That is the Environmental Health Division's program of food facility closure. The suspensions and revocations of permits may have an unmeasured contributing effect on the disease cycle. Los Angeles County has a proactive policy about stopping hazardous operations from continuing regardless of the grading, and retail food facilities may be prevented from continuing to operate and serve the public through this closure system. When a high-risk violation that may affect safe operation is observed, immediate intervention is taken to stop the operation. Posting the notice of closure at the food facility is an integral part of the grading-system process.

Sadly, it is a reality that facilities have their operations stopped because of high-risk violations. The use of this regulatory tool, as it is designated in the California Health and Safety Code, is extremely effective in preventing hazardous conditions from continuing. Yes, it is presumptive that facilities earning poorer grades may have the highest risk factors for causation of FBI. The closure condition may, however, occur regardless of the grade. I am unaware of any published data on the impact of the closure process, although they may be available. Personal experience has shown that facilities that are directed to cease operations generally have less recidivism for high-risk violations. The operators take serious initiative to enhance their "sanitation" after experiencing the department's closure process.

The closure process intervention tool is used by the department's environmental health staff when appropriate and may be accompanied by a referral for criminal prosecution of violations. Thus, the closure process and the diligent job that the "inspectors" do also play a part in the intervention into the hazardous conditions that may contribute to FBI. I commend the Los Angeles County Health Department and especially its Environmental Health Division staff for their dedication and their serious efforts to reduce FBI not only through grading, but also through the accompanying use of the state regulatory closure protocols. I believe this is as yet an unmeasured variable in L.A. County's success in the reduction of foodborne illnesses.

Respectfully,

Adam R. Rocke, M.S., R.E.H.S., R.E.A.

Retired Los Angeles County Environmental Health Service Manager

Co-authors Simon, Leslie, Aguirre, and Fielding respond:

We agree with Mr. Rocke that restaurant closures and other aspects of the inspection process aside from grade cards have the potential to prevent foodborne illness among consumers. As we noted in our paper, although we believe the grade cards were the primary driving force for the observed reduction in foodborne-disease hospitalizations, we cannot exclude the possibility that several other changes in the program may have also contributed.

The closure policy was modified in December 1997 to include more precise parameters for closure (e.g., mandatory 48-hour closure for vermin). In addition, the number of restaurant closures increased from 803 in 1997 to 1,343 in 1998 and then decreased to 1,000 in 1999 and 975 in 2000. A similar trend was observed for markets and retail food processors. Among retail food establishments that experienced one or more closures, an increase in inspection scores was observed from pre- to postclosure inspections. This increase, however, was much more pronounced in 1997 (an 18.3-point average increase for restaurants), prior to the introduction of the grade cards, than in 1998 (an 8.7-point increase), 1999 (a 5.4-point increase), and 2000 (a 2.6-point increase). In addition, preclosure inspection scores increased during this period, from an average of 69.1 in 1997 to 80.2 in 1998, 84.2 in 1999, and 86.3 in 2000. This trend suggests that, among these establishments, closures may have had a diminishing effect on improving restaurant hygiene after the grade cards were implemented because of the improved baseline hygiene associated with the grade cards.

While we believe grade cards are an effective tool for improving hygienic conditions in restaurants, there may be other tools. Among these, restaurant closures have in common with grade cards that they imply an economic incentive for restaurants to pursue good-quality hygiene. In each case, restaurant revenues are affected by the outcome of inspection. This effect is in contrast to other aspects of the inspection process that provide no clear economic incentive for restaurants to ensure hygienic conditions. For example, when inspectors educate restaurant employees in safe food-handling practices, there is no clear penalty if the employees choose to ignore the advice. That is not to say that such educational efforts are wasted. Rather, it suggests that economic incentives may not be the main reason why such educational efforts are effective in improving restaurant hygiene. Closures and grade cards, on the other hand, imply economic incentives for good hygiene.

Sincerely,

Paul A. Simon, M.D., M.P.H.

Phillip Leslie, Ph.D.

Arturo Aguirre, M.A., R.E.H.S.

Jonathan E. Fielding, M.D., M.P.H.