Engaging Local Health Departments to Identify Food Safety Best Practices During a Public Health Emergency : Journal of Public Health Management and Practice

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Engaging Local Health Departments to Identify Food Safety Best Practices During a Public Health Emergency

Puwalski, Stephanie MA, MPH; Turay, Olivia MPH; Papagni, Noah BA; Adams, Nicholas MHS

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Journal of Public Health Management and Practice: November/December 2022 - Volume 28 - Issue 6 - p 751-753
doi: 10.1097/PHH.0000000000001643
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The coronavirus (COVID-19) pandemic was an extremely challenging period for public health agencies throughout the world. It also highlighted serious shortcomings in the ability to respond to community needs and to promote public health throughout the United States. Local health departments (LHDs) with environmental health teams were among those significantly impacted by the COVID-19 pandemic. While some agencies managed to maintain a portion of their normal regulatory duties, many experienced a disruption of these activities because of reduced staffing, a shifting focus toward COVID-19 response, and changing priorities to provide support for relief efforts such as vaccination clinics.1 Over the past year, the National Association of County and City Health Officials (NACCHO) has worked with LHDs, represented by members of its Food Safety Workgroup, to identify factors of the COVID-19 pandemic that impacted food safety practices and to develop recommendations to overcome these challenges. Examples of issues encountered at the local level were institutional settings closing doors due to an increased risk of infection and mortality2,3; restaurants shutting down operations due to local ordinances and staff shortages4; and mixed acceptance of virtual inspections. All of this made it extremely difficult for LHDs to conduct routine food inspections during the pandemic. In the face of these external factors, environmental health managers had to balance the risk of exposing sanitarians to COVID-19 during in-person inspections with the reward of protecting the public from foodborne pathogens. In collaboration with LHDs, NACCHO has identified recommendations for retail food regulatory programs to prepare for the next public health emergency.

Issues Faced During the COVID-19 Pandemic

There were 5 main challenges identified as impacting food safety practices at the local level: distrust of public health practitioners; inspectors facing threats and harassment; challenges with contact tracing and tracing foodborne illness outbreaks; difficulty prioritizing routine food safety activities; and challenges with conducting virtual inspections. The pandemic has eroded confidence in federal, state, and local public health agencies. While most of the US population believes that public health agencies are doing important work, approval of the public health system has declined from 43% to 34% between 2009 and 2021.5 A national survey conducted in 2021 found that 44% of the US population trusts the recommendations of LHDs a great deal, while 18% do not trust information from LHDs.5 In addition, more than 1 in 5 adults feel that the information provided by LHDs is unreliable, creating even more stress for public health practitioners.6 Systemic racism has also had a detrimental effect on trust in the public health infrastructure and has exacerbated health disparities.7 Distrust of LHDs creates a hostile environment for sanitarians who are in the field every day working with individuals from the community, significantly reducing the impact of retail food regulatory programs in preventing foodborne illness outbreaks.

Another issue that LHDs experienced during the pandemic was an increase in threats and harassment. A national survey conducted by NACCHO spanning March 2020 to January 2021 found that there was a high level of harassment directed at public health officials. Among 583 LHD survey respondents, 335 departments reported a total of 1499 incidents of harassment.8 Moreover, 222 public health officials reported leaving their positions and 36% of these departures occurred alongside reports of harassment.8 Public health officials described experiencing threats, intimidation, and resulting stress intolerance and mental health conditions. Despite staying in their jobs, public health officials described feeling that their work was underrecognized and underappreciated and that they experienced a loss of meaningfulness in their work.8 Within retail food regulatory programs that were NACCHO members, many have described stories of inspectors being threatened and harassed when attempting to perform routine retail food inspections, as food service operators blamed them for restaurant closures and COVID-19 mandates in the community. Being the face of public health in the community became significantly more difficult when the majority of community members were confused about vital public health recommendations.9

In addition, LHDs experienced difficulties while trying to gather accurate information during COVID-19 contact tracing efforts.10 Contact tracing played a key part in mitigating the spread of COVID-19; yet, at the height of the pandemic, 41% of individuals surveyed responded that they would not participate or would not be likely to participate in contact tracing activities if called by an LHD representative.10 Similarly, LHDs struggled to trace foodborne illness outbreaks during the pandemic and crucial food safety practices such as contact tracing became more challenging. Furthermore, with staff being pulled for pandemic response activities and with COVID-19–related absences in LHDs, NACCHO members found it difficult to prioritize needs that were not directly related to emergency response. Even when staff were available, retail food regulatory programs found it difficult to prioritize which establishments should be inspected first.

Finally, LHDs experienced many challenges with conducting inspections virtually instead of in person. For example, some jurisdictions adopted virtual inspections to limit staff exposure to the coronovirus,11 but in some instances, legislatures refused to accept virtual inspections for regulatory purposes. While technology allows for LHDs to connect with food service operators without the risk of disease transmission, concerns such as losing signal during an inspection, seeing all activities in the establishment, and increasing risk by taking time away from an operator who was short-staffed led many NACCHO members to shy away from using virtual methods. Hesitancy in adopting virtual inspections stems from the lack of proof of concept for evaluating the feasibility of using remote inspections.12 These challenges made completing routine food safety activities extremely difficult during the pandemic and have created tensions in the public health infrastructure that may limit the success of LHDs long after the pandemic is contained.

Recommendations: How Can Retail Food Regulatory Programs Be Better Prepared for the Next Public Health Emergency?

The primary recommendation for LHDs is to foster communication and positive relationships with food service establishments. Clear messaging, collaborative relationships, and inclusion of stakeholders in decision making are key steps to rebuilding trust between public health professionals and the communities that they serve.13 The messaging must explain the information being used to make decisions, as well as share the work being done to fill existing knowledge gaps.14 In addition, LHDs recommended considering racial and other social factors in decision making and improving relationships with underserved communities. Establishing an open dialogue between public health practitioners and communities during nonemergency times can help build rapport with vulnerable populations and establish trust prior to a public health emergency. For example, a food regulator can build trust among its operators when instructing food safety practices. Public health practitioners can also build trust with consumers using targeted messaging about safe food handling practices among low-income and minority populations. This may help contribute to better food safety behaviors among these vulnerable populations.15 LHDs also recommended improving efforts to conduct effective virtual inspections. Suggested strategies are summarized in a factsheet16 developed by NACCHO in collaboration with its Food Safety Workgroup. Some of the recommendations include improving the use of technology for inspections, shifting from regulation to education, and reframing interactions between regulators and food service operators.16

LHDs proposed using food safety culture to characterize retail food establishments by identifying “high-risk” establishments, thereby prioritizing regulatory and education efforts that will have the greatest impact on reducing foodborne illness. The US Food and Drug Administration (FDA) notes the importance of food safety culture in retail food establishments as a core tenet of reducing foodborne illness.12 In the New Era of Smarter Food Safety blueprint, the FDA suggests that public health practitioners consider how positive food safety culture can be used as a rationale for reduced inspection frequency. The same method could be used to characterize food service operations by their foodborne illness risk and identify those that need to be prioritized during a public health emergency. To do so, characteristics that indicate an establishment's food safety culture need to be standardized and inspectors need to be educated on how to evaluate those characteristics during routine inspections.

In addition, LHDs stressed the importance of conducting a “hotwash,” or an immediate evaluation of performance, following a major event. A template for LHDs, specifically retail food regulatory programs, to conduct a hotwash following the COVID-19 response should be created and disseminated to help these programs identify successes and failures regarding their operations during the pandemic. Finally, LHDs should develop and implement support structures within the workplace to ensure the personal and professional safety of public health practitioners, especially staff in the field performing food safety inspections. It is also important to develop more formalized reporting systems to detect, monitor, and report harassment.

References

1. Kaiser Family Foundation. Community health centers are a key source of COVID-19 rapid at-home self-tests for hard-to-reach groups. https://www.kff.org/policy-watch/community-health-centers-are-a-key-source-of-covid-19-rapid-at-home-self-tests-for-hard-to-reach-groups. Published January 2022. Accessed May 31, 2022.
2. Centers for Disease Control and Prevention. People who live in a nursing home or long-term care facility. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-in-nursing-homes.html. Accessed May 31, 2022.
3. Marquez N, Ward JA, Parish K, Saloner B, Dolovich S. COVID-19 incidence and mortality in federal and state prisons compared with the US population, April 5, 2020, to April 3, 2021. JAMA. 2021;326(18):1865–1867.
4. Restaurant Business. Labor shortfall erased for restaurants in February, new stats show. https://www.restaurantbusinessonline.com/workforce/labor-shortfall-eased-restaurants-february-new-stats-show. Accessed May 31, 2022.
5. Robert Wood Johnson Foundation. The public's perspective on the United States public health system. www.rwjf.org/en/library/research/2021/05/the-publics-perspective-on-the-united-states-public-health-system.html. Accessed May 31, 2022.
6. Ho A, Huang V. Unmasking the ethics of public health messaging in a pandemic. J Bioeth Inq. 2021;18(4):549–559.
7. US Food and Drug Administration. New era of smarter food safety—FDA's blueprint for the future. www.Fda.gov/media/139868/download. Accessed May 31, 2022.
8. Ward JA, Stone EM, Mui P, Resnick B. Pandemic-related workplace violence and its impact on public health officials, March 2020-January 2021. Am J Public Health. 2022;112(5):736–746.
9. Pew Research Center. Two years into the pandemic, Americans inch closer to a new normal. https://www.pewresearch.org/2022/03/03/two-years-into-the-pandemic-americans-inch-closer-to-a-new-normal. Accessed May 31, 2022.
10. Pew Research Center. The challenges of contact tracing as U.S. battles COVID-19. https://www.pewresearch.org/internet/2020/10/30/the-challenges-of-contact-tracing-as-u-s-battles-covid-19. Accessed May 31, 2022.
11. Association of State and Territorial Health Officials. Virtual food safety inspections during the COVID-19 pandemic. https://www.astho.org/globalassets/brief/vritual-food-safety-inspections-during-the-covid-19-pandemic.Pdf. Accessed May 31, 2022.
12. The White House Briefing Room. Factsheet: Biden-Harris Administration to Invest $7 billion from American Rescue Plan to hire and train public health workers in response to COVID-19. https://www.whitehouse.gov/briefing-room/statements-releases/2021/05/13/fact-sheet-biden-harris-administration-to-invest-7-billion-from-american-rescue-plan-to-hire-and-train-public-health-workers-in-response-to-covid-19. Accessed May 31, 2022.
13. Cheng T, Horbay B, Nocos R, Lutes L, Lear SA. The role of tailored public health messaging to young adults during COVID-19: “there's a lot of ambiguity around what it means to be safe.” PLoS One. 2021;16(10):e0258121.
14. Best AL, Fletcher FE, Kadono M, Warren RC. Institutional distrust among African Americans and building trustworthiness in the COVID-19 response: implications for ethical public health practice. J Health Care Poor Underserved. 2021;32(1):90–98.
15. Quinlan JJ. Foodborne illness incidence rates and food safety risks for populations of low socioeconomic status and minority race/ethnicity: a review of the literature. Int J Environ Res Public Health. 2013;10(8):3634–3652.
16. National Association of County and City Health Officials. Virtual inspections of food service establishments through risk-based inspections. https://bit.ly/virtualfoodsafetyinspections. Accessed August 1, 2022.
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