Improving Cost Estimates for Risk-Based Food Safety Management and Policy

Over the past several decades, the food safety community has worked to develop and strengthen risk-based systems to prevent foodborne disease. Periodic assessments of the burden of foodborne disease (illnesses, Health-related Quality of Life Years, and economic) are foundational to this work. The article by Hoffmann and colleagues in this issue of Foodborne Pathogens and Disease provides new estimates of the economic burden of foodborne disease in the United States. Economic estimates are just one way to measure disease burden but have the advantage of providing a summary measure of the overall disease burden from acute illnesses, complications, and long-term sequelae that is needed for regulatory cost-benefit analysis and communication with decision-makers and the broader public. These new cost estimates are among the most comprehensive yet produced for the United States but represent only the most recent effort in a 4-decade long process of improving the data available for decision-making.

The rise of risk-based food safety management and policy is part of a broader movement in controlling population health risks. In the early 1980’s, the National Research Council ushered in the modern era of U.S. environmental and population health policy by laying out a coherent framework for risk assessment and risk management informed by scientific risk assessment—what we have since called risk analysis (NRC, 1983). This work was initially focused on better environmental risk management, but the applicability to other population health risks was not lost on the food safety community. In 1989, the Council for Agricultural Science and Technology (CAST) formed a task force charged with developing a comprehensive system for assessing risk from foodborne microbial hazards. The task force identified lack of comprehensive data on foodborne disease risks and their impacts as a barrier to building a strong foundation for both assessment and management of these risks (CAST, 1994). Specifically, the CAST task force called for creation of an enhanced information database on foodborne illness that would include comprehensive estimates of the number of acute illnesses, deaths and chronic illnesses from microbial pathogens, the duration and severity of these illnesses, and their cost.

During the 1980s, researchers attempted to estimate the burden of foodborne disease for specific pathogens, but these efforts were based on limited or incomplete existing information (Roberts, 1989; Todd, 1989). In 1995, the Foodborne Disease Active Surveillance Network (FoodNet), a sentinel system of active surveillance of 9 potentially foodborne infections in 10 states, was established (CDC, 2023; Scallan, 2007). Importantly, FoodNet also worked to determine the overall human-health impact of foodborne illness by conducting related epidemiological studies—including the FoodNet Population Survey and surveys of laboratory practices. By estimating the frequency of cases of foodborne disease that go undetected at each surveillance step (seeking of medical care, stool specimen submission, and laboratory testing), FoodNet surveys were able to account for surveillance gaps and, therefore, allow an extrapolation from laboratory-confirmed cases to estimate the overall number of illnesses in the community. In 1999, Paul Mead and coauthors used data from FoodNet surveillance and surveys, along with other sources, to estimate the total incidence (illnesses, hospitalizations and deaths) of 28 major foodborne illnesses (Mead et al., 1999). These were the first comprehensive set of US foodborne illness estimates and a basis for quantitatively prioritizing among pathogens. Since then, Scallan and coauthors published an expanded set of foodborne illness estimates (Scallan et al., 2011a, b), including estimates of the burden on children and older people and using Disability adjusted life years (DALYs) (Scallan et al., 2015a, 2015b; Scallan et al., 2013). Work continues at CDC on updating and modernizing illness estimates.

CDC’s illness estimates opened the door to filling out the information infrastructure required by regulators and envisioned in the 1989 CAST report. Multiple research efforts used these disease outcome estimates to produced more comprehensive economic estimates (Frenzen et al., 2005; Hoffmann et al., 2012; Minor et al., 2015; Scharff, 2012). An effort led by Michael Taylor and Glenn Morris at Resources for the Future and the University of Florida developed a coordinated set of economic, QALY, and food source attribution estimates for 15 leading pathogens, demonstrating the feasibility of the CAST task force’s vision (Batz et al., 2014; Batz et al., 2012; Hoffmann et al. 2008, Hoffmann et al., 2012; Morris et al., 2011). These economic estimates became the ERS Cost of Foodborne Illness Data Product (ERS, 2023). In 2021, ERS updated these estimates to in 2018 dollars or $17.6 billion (Hoffmann and Ahn, 2021).

The estimates published in this issue of Foodborne Pathogens and Disease revise the ERS cost of foodborne illness estimates. They expand coverage to include all 31 pathogens plus unspecified agents in Scallan et al. 2011a, 2011b and improve the uncertainty modeling. Importantly, they provide a more complete picture possible of foodborne illness chronic sequelae and their impacts, basing estimates on new comprehensive reviews of current scientific literature. Sequelae from foodborne diseases has been an understudied area of epidemiological research and recent studies suggest that the long-term health impacts of acute foodborne infections are more extensive than previously understood. This new economic study shows the importance of measuring the impact of sequelae. Sequelae account for 31% of total cost for all foodborne illnesses and 52% of total costs of disease from the known pathogens. The impact of more accurate accounting for sequelae can be seen by comparing sequelae cost results for the same 15 pathogens (based on the same acute case incidence estimates) in the 2018 study (15% of total costs) with the new study (39% of total costs). Both experts at workshop we held to advise us on sequelae, and our subsequent literature reviews, identify a great need for more epidemiological research on the chronic impacts of infectious illness, including foodborne illness (Hoffmann and Scallan 2020). This research needs to estimate not only the frequency of clinical diagnoses (e.g., chorioretinitis), but also impact on people’s lives (e.g., the level of vision impairment), as estimates of impacts are required for economic valuations. What is needed more broadly is for researchers to consider how their research will be used in burden estimates and policy analysis when designing studies.