摘要：Objectives. In collaboration with Public Health Practice–Based Research Networks, we investigated relationships between local health department (LHD) food safety and sanitation expenditures and reported enteric disease rates. Methods. We combined annual infection rates for the common notifiable enteric diseases with uniquely detailed, LHD-level food safety and sanitation annual expenditure data obtained from Washington and New York state health departments. We used a multivariate panel time-series design to examine ecologic relationships between 2000–2010 local food safety and sanitation expenditures and enteric diseases. Our study population consisted of 72 LHDs (mostly serving county-level jurisdictions) in Washington and New York. Results. While controlling for other factors, we found significant associations between higher LHD food and sanitation spending and a lower incidence of salmonellosis in Washington and a lower incidence of cryptosporidiosis in New York. Conclusions. Local public health expenditures on food and sanitation services are important because of their association with certain health indicators. Our study supports the need for program-specific LHD service-related data to measure the cost, performance, and outcomes of prevention efforts to inform practice and policymaking. Local health department (LHD) resources are intended to be spent on improving health, protecting the public from disease and disability, and reducing disparities. 1 Although LHDs differ across states and communities in services provided and approaches to health improvement, one of the most common LHD activities is the performance of food safety and sanitation education and inspection. 2,3 Yet, as in other areas of LHD service, 4 local public health leaders lack the data and evidence needed to direct decision making and advocacy regarding the value of these food safety and sanitation efforts and expenditures. In the face of major US budget cuts and job losses in LHDs in recent years, 5 the need for evidence to direct resources effectively has become urgent. Food safety and sanitation activities are regulated by federal, state, and local governments, with many state and local health departments adopting the Food and Drug Administration’s food code model to ensure food safety. 6 At the state level, state health departments enact legislation and regulation and execute “police powers” in food safety. State and local health department responsibilities include licensing food establishments, inspecting food storage warehouses to ensure required food storage compliance, and authorizing temporarily restricted employment of food service workers with certain contagious diseases. The extent and independence of LHD activities regarding food safety and sanitation vary widely across states, with the authority for an LHD’s independence generally delegated by the state. State or local staff from agencies other than health departments, for example, are sometimes responsible for local food safety inspections and enforcement. In many states, including Washington and New York, LHD officials often have authority to perform food establishment licensing, food inspections, restriction of ill food workers, and other areas of inspection and licensing that are carried out to protect the public from foodborne illness. Related LHD food safety budgets are often influenced by number of restaurants, inspections, training, and technology. 7–11 LHD responsibilities extend to facility sanitation services, with health departments often charged with testing and regulation of public and recreational areas and water sources. Additional LHD functions may include providing laboratory services and partnering with other agencies (such as the US Department of Agriculture, Centers for Disease Control and Prevention, and food service industries) in public education, disease surveillance, and response to outbreaks of food and waterborne disease. A limited number of published studies have identified relationships between sanitation measures and health, with research complicated by the fact that no simple water quality indicator accurately predicts illness across diverse water source environments. 12,13 Local efforts supporting inspection, education, and food code enforcement related to food and water are intended to reduce the incidence of enteric diseases such as norovirus, Salmonella, and Clostridium perfringens . 11,14,15 Supporting research, however, has been inconclusive. Evidence from a study of 1 county, for example, indicated that routine restaurant inspection could predict the likelihood of an enteric disease outbreak, 16 but other studies have found that restaurant inspection scores are not associated with foodborne outbreaks. 14,17–19 Few published studies have actually examined the performance of LHD disease prevention efforts in relation to food safety (e.g., restaurant inspection, water quality testing) to see whether those efforts reduce rates of the enteric diseases they try to prevent. 19 Inconsistent and inadequate amounts of research regarding food safety and sanitation practices leave public health leaders with little evidence on which to establish their approach to these activities. 14 This lack of research may have contributed to environmental health programs—the programs that oversee food safety and sanitation activities—being among those most affected by recent LHD budget cuts. 5 Better evidence would support advocacy for the staff, programs, and funding that have long been thought to be reasonably expected to protect the public’s health. LHD service-specific expenditures do not always align with related local need. 20 This is also true of public health system expenditures for food safety, sanitation, and other environmental health–related services. 21 Studies have indicated, for example, that activities such as restaurant inspections are not always carried out at a frequency and depth that is responsive to recent rates of enteric disease. 22,23 A lack of detailed data interferes greatly with producing the evidence public health leaders require for policymaking regarding the contribution and distribution of these services relative to need. 24 The same lack of data has hampered the development of evidence and direction for decision making in terms of other LHD services. 4,25 In collaboration with statewide Public Health Practice–Based Research Networks (PBRNs) in Washington and New York, the University of Washington’s Public Health Activities and Services Tracking research team compiled uniquely detailed annual LHD expenditure data specific to food safety and sanitation. We used these expenditure data as a proxy for public health food safety and sanitation services and linked them to notifiable enteric disease data in those states. Previous studies have shown that LHD expenditure data can be used to demonstrate critical relationships between LHD output and community health. 4,26,27 The purpose of our study was to determine whether higher LHD food safety and facility sanitation expenditures were associated with fewer enteric infections. The results provide evidence regarding the value of these LHD service investments and help address questions regarding the impact of LHD food safety or facility sanitation services on the public’s health.
