Diminishing Willingness to Pay per Quality‐Adjusted Life Year: Valuing Acute Foodborne Illness

We design and conduct a stated‐preference survey to estimate willingness to pay (WTP) to reduce foodborne risk of acute illness and to test whether WTP is proportional to the corresponding gain in expected quality‐adjusted life years (QALYs). If QALYs measure utility for health, then economic theory requires WTP to be nearly proportional to changes in both health quality and duration of illness and WTP could be estimated by multiplying the expected change in QALYs by an appropriate monetary value. WTP is elicited using double‐bounded, dichotomous‐choice questions in which respondents (randomly selected from the U.S. general adult population, n = 2,858) decide whether to purchase a more expensive food to reduce the risk of foodborne illness. Health risks vary by baseline probability of illness, reduction in probability, duration and severity of illness, and conditional probability of mortality. The expected gain in QALYs is calculated using respondent‐assessed decrements in health‐related quality of life if ill combined with the duration of illness and reduction in probability specified in the survey. We find sharply diminishing marginal WTP for severity and duration of illness prevented. Our results suggest that individuals do not have a constant rate of WTP per QALY, which implies that WTP cannot be accurately estimated by multiplying the change in QALYs by an appropriate monetary value.     

A Bayesian Evidence Synthesis for Estimating Campylobacteriosis Prevalence

Stakeholders making decisions in public health and world trade need improved estimations of the burden‐of‐illness of foodborne infectious diseases. In this article, we propose a Bayesian meta‐analysis or more precisely a Bayesian evidence synthesis to assess the burden‐of‐illness of campylobacteriosis in France. Using this case study, we investigate campylobacteriosis prevalence, as well as the probabilities of different events that guide the disease pathway, by (i) employing a Bayesian approach on French and foreign human studies (from active surveillance systems, laboratory surveys, physician surveys, epidemiological surveys, and so on) through the chain of events that occur during an episode of illness and (ii) including expert knowledge about this chain of events. We split the target population using an exhaustive and exclusive partition based on health status and the level of disease investigation. We assume an approximate multinomial model over this population partition. Thereby, each observed data set related to the partition brings information on the parameters of the multinomial model, improving burden‐of‐illness parameter estimates that can be deduced from the parameters of the basic multinomial model. This multinomial model serves as a core model to perform a Bayesian evidence synthesis. Expert knowledge is introduced by way of pseudo‐data. The result is a global estimation of the burden‐of‐illness parameters with their accompanying uncertainty.     

New Data,Strategies, and Insights for Listeria monocytogenes Dose‐Response Models: Summary of an Interagency Workshop, 2011

Listeria monocytogenes is a leading cause of hospitalization, fetal loss, and death due to foodborne illnesses in the United States. A quantitative assessment of the relative risk of listeriosis associated with the consumption of 23 selected categories of ready‐to‐eat foods, published by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture in 2003, has been instrumental in identifying the food products and practices that pose the greatest listeriosis risk and has guided the evaluation of potential intervention strategies. Dose‐response models, which quantify the relationship between an exposure dose and the probability of adverse health outcomes, were essential components of the risk assessment. However, because of data gaps and limitations in the available data and modeling approaches, considerable uncertainty existed. Since publication of the risk assessment, new data have become available for modeling L. monocytogenes dose‐response. At the same time, recent advances in the understanding of L. monocytogenes pathophysiology and strain diversity have warranted a critical reevaluation of the published dose‐response models. To discuss strategies for modeling L. monocytogenes dose‐response, the Interagency Risk Assessment Consortium (IRAC) and the Joint Institute for Food Safety and Applied Nutrition (JIFSAN) held a scientific workshop in 2011 (details available at http://foodrisk.org/irac/events/ ). The main findings of the workshop and the most current and relevant data identified during the workshop are summarized and presented in the context of L. monocytogenes dose‐response. This article also discusses new insights on dose‐response modeling for L. monocytogenes and research opportunities to meet future needs.     

Risk Ranking for Foodborne Microbial Hazards in New Zealand: Burden of Disease Estimates

Priority setting for food safety management at a national level requires risks to be ranked according to defined criteria. In this study, two approaches (disability‐adjusted life years (DALYs) and cost of illness (COI)) were used to generate estimates of the burden of disease for certain potentially foodborne diseases (campylobacteriosis, salmonellosis, listeriosis (invasive, perinatal, and nonperinatal), infection with Shiga toxin‐producing Escherichia coli (STEC), yersiniosis, and norovirus infection) and their sequelae in New Zealand. A modified Delphi approach was used to estimate the food‐attributable proportion for these diseases. The two approaches gave a similar ranking for the selected diseases, with campylobacteriosis and its sequelae accounting for the greatest proportion of the overall burden of disease by far.     

Leveraging risk assessment for foodborne outbreak investigations: The Quantitative Risk Assessment-Epidemic Curve Prediction Model

Root cause analysis can be used in foodborne illness outbreak investigations to determine the underlying causes of an outbreak and to help identify actions that could be taken to prevent future outbreaks. We developed a new tool, the Quantitative Risk Assessment-Epidemic Curve Prediction Model (QRA-EC), to assist with these goals and applied it to a case study to investigate and illustrate the utility of leveraging quantitative risk assessment to provide unique insights for foodborne illness outbreak root cause analysis. We used a 2019 Salmonella outbreak linked to melons as a case study to demonstrate the utility of this model (Centers for Disease Control and Prevention [CDC], 2019). The model was used to evaluate the impact of various root cause hypotheses (representing different contamination sources and food safety system failures in the melon supply chain) on the predicted number and timeline of illnesses. The predicted number of illnesses varied by contamination source and was strongly impacted by the prevalence and level of Salmonella contamination on the surface/inside of whole melons and inside contamination niches on equipment surfaces. The timeline of illnesses was most strongly impacted by equipment sanitation efficacy for contamination niches. Evaluations of a wide range of scenarios representing various potential root causes enabled us to identify which hypotheses, were likely to result in an outbreak of similar size and illness timeline to the 2019 Salmonella melon outbreak. The QRA-EC framework can be adapted to accommodate any food–pathogen pairs to provide insights for foodborne outbreak investigations.     

Communicating Food Risks in an Era of Growing Public Distrust: Three Case Studies

The communication and regulation of risk has changed significantly over the past 30 years in Europe and to a noticeable but lesser extent in the United States. In Europe, this is partly due to a series of regulatory mishaps, ranging from mad cow disease in the United Kingdom to contamination of the blood supply in France. In the United States, general public confidence in the American government has been gradually declining for more than three decades, driven by a mix of cultural and political conflicts like negative political advertising, a corrosive news media, and cuts in regulatory budgets. While the former approach is based on an objective assessment of the risk, the latter is driven more by the perception of the risk, consumer sentiment, political will, and sectoral advocacy. In this article, the author examines three U.S.‐based food case studies (acrylamide, bisphenol A, and artificial food colorings) where regulations at the local and state levels are increasingly being based on perceived risk advocacy rather than on the most effective response to the risk, be it to food safety or public health, as defined by regulatory interpretation of existing data. In the final section, the author puts forward a series of recommendations for how U.S.‐based regulators can best handle those situations where the perceived risk is markedly different from the fact‐based risk, such as strengthening the communication departments of food regulatory agencies, training officials in risk communication, and working more proactively with neutral third‐party experts.     

Risk Communication and Foodborne Illness: Message Sponsorship and Attempts to Stimulate Perceptions of Risk

Foodborne illness represents a serious health hazard in the United States. Since foodborne illness can often be prevented by an individual's behavior, messages aimed at promoting safe food-handling behaviors should be a major tool to reduce the incidence of foodborne illness. This article argues that to achieve adoption of safe food-handling practices in the home, food-safety messages should both stimulate risk perceptions and promote self-efficacy, feelings that one can successfully enact recommended behaviors. A content analysis of nationally distributed food-safety messages questioned if messages incorporated these features. Since food-safety communicators operate in complex environments with multiple and sometimes competing objectives, this study also questioned if sponsorship of foodborne illness prevention messages was related to the amount of content designed to alter risk perceptions associated with foodborne illness. Results of the quantitative content analysis found that copywriters generally included content designed to stimulate risk perception about foodborne illness but virtually ignored self-efficacy needs of the audience. A marked difference in tendencies to stimulate risk perceptions was found based on sponsorship. Both in volume and proportion, results show that governmentally sponsored messages more aggressively attempted to heighten risk perceptions associated with foodborne illness than did messages sponsored by privately funded communicators.     

Quantifying Potential Human Health Impacts of Animal Antibiotic Use: Enrofloxacin and Macrolides in Chickens

Use of similar or identical antibiotics in both human and veterinary medicine has come under increasing scrutiny by regulators concerned that bacteria resistant to animal antibiotics will infect people and resist treatment with similar human antibiotics, leading to excess illnesses and deaths. Scientists, regulators, and interest groups in the United States and Europe have urged bans on nontherapeutic and some therapeutic uses of animal antibiotics to protect human health. Many regulators and public health experts have also expressed dissatisfaction with the perceived limitations of quantitative risk assessment and have proposed alternative qualitative and judgmental approaches ranging from "attributable fraction" estimates to risk management recommendations based on the precautionary principle or on expert judgments about the importance of classes of compounds in human medicine. This article presents a more traditional quantitative risk assessment of the likely human health impacts of continuing versus withdrawing use of fluoroquinolones and macrolides in production of broiler chickens in the United States. An analytic framework is developed and applied to available data. It indicates that withdrawing animal antibiotics can cause far more human illness-days than it would prevent: the estimated human BENEFIT:RISK health ratio for human health impacts of continued animal antibiotic use exceeds 1,000:1 in many cases. This conclusion is driven by a hypothesized causal sequence in which withdrawing animal antibiotic use increases illnesses rates in animals, microbial loads in servings from the affected animals, and hence human health risks. This potentially important aspect of human health risk assessment for animal antibiotics has not previously been quantified.     

The Bayesian Microbial Subtyping Attribution Model: Robustness to Prior Information and a Proposition

Attributing foodborne illnesses to food sources is essential to conceive, prioritize, and assess the impact of public health policy measures. The Bayesian microbial subtyping attribution model by Hald et al. is one of the most advanced approaches to attribute sporadic cases; it namely allows taking into account the level of exposure to the sources and the differences between bacterial types and between sources. This step forward requires introducing type and source‐dependent parameters, and generates overparameterization, which was addressed in Hald's paper by setting some parameters to constant values. We question the impact of the choices made for the parameterization (parameters set and values used) on model robustness and propose an alternative parameterization for the Hald model. We illustrate this analysis with the 2005 French data set of non‐typhi Salmonella. Mullner's modified Hald model and a simple deterministic model were used to compare the results and assess the accuracy of the estimates. Setting the parameters for bacterial types specific to a unique source instead of the most frequent one and using data‐based values instead of arbitrary values enhanced the convergence and adequacy of the estimates and led to attribution estimates consistent with the other models’ results. The type and source parameters estimates were also coherent with Mullner's model estimates. The model appeared to be highly sensitive to parameterization. The proposed solution based on specific types and data‐based values improved the robustness of estimates and enabled the use of this highly valuable tool successfully with the French data set.     

Evaluating Efficiency-Equality Tradeoffs for Mobile Source Control Strategies in an Urban Area

In environmental risk management, there are often interests in maximizing public health benefits (efficiency) and addressing inequality in the distribution of health outcomes. However, both dimensions are not generally considered within a single analytical framework. In this study, we estimate both total population health benefits and changes in quantitative indicators of health inequality for a number of alternative spatial distributions of diesel particulate filter retrofits across half of an urban bus fleet in Boston, Massachusetts. We focus on the impact of emissions controls on primary fine particulate matter (PM_2.5) emissions, modeling the effect on PM_2.5 concentrations and premature mortality. Given spatial heterogeneity in baseline mortality rates, we apply the Atkinson index and other inequality indicators to quantify changes in the distribution of mortality risk. Across the different spatial distributions of control strategies, the public health benefits varied by more than a factor of two, related to factors such as mileage driven per day, population density near roadways, and baseline mortality rates in exposed populations. Changes in health inequality indicators varied across control strategies, with the subset of optimal strategies considering both efficiency and equality generally robust across different parametric assumptions and inequality indicators. Our analysis demonstrates the viability of formal analytical approaches to jointly address both efficiency and equality in risk assessment, providing a tool for decisionmakers who wish to consider both issues.     

Visualization of Innovation in Global Supply Chain Networks

This methodological note identifies and describes a data‐driven visualization approach to study innovations in supply chain networks (ISCN). We demonstrate its value and applicability with illustrative examples to pertinent structure‐related ISCN research questions in the global electronics industry. Our visualization approach can be used to reveal and understand important clusters, patterns, trends, and outliers of ISCN not necessarily identified with traditional methods. The broader aim of this note is to demonstrate the complementary value of emerging visual analytic approaches in managerial decision‐making contexts and describe how actionable insights can be achieved.     

环境污染、经济增长与医疗卫生服务对公共健康的影响分析——基于中国省际面板数据的研究

环境污染与经济增长对居民的公共健康水平有重要影响,但基于面板数据对此问题分区域的研究较少。本文在Grossman健康生产函数的基础上加入环境污染等多重因素,使用中国30个省市区1997年到2010年的面板数据,建立个体固定效应模型,将我国划分为东部、中部和西部三个区域,实证分析了环境污染、经济增长与医疗卫生服务对不同区域居民公共健康的影响及其差异。研究发现:环境污染、经济增长、医疗卫生服务与居民公共健康存在长期均衡的协整关系,经济增长与全国、东部和中部的公共健康关系呈现倒U型的特征;具体而言:东部区域,曲线已达到拐点,中部区域,当人均GDP为3311元时,曲线达到拐点;全国以及东、中、西部区域,工业烟尘排放量与人口死亡率呈正向关关系,工业二氧化硫排放量与人口死亡率只在中部地区显著正相关;全国、东部和中部区域人均医生数与人口死亡率呈显著负相关,西部地区未呈现这一特性;人均医疗保健支出与人口死亡率在中部地区显著负相关,医疗卫生服务可有效减少环境污染对居民的健康威胁。因此,制定差别化的环境污染、经济增长与医疗服务政策等有利于提升全国以及东中西部居民的公共健康水平。     

Selecting human health metrics for environmental decision-support tools.

Environmental decision‐support tools often predict a multitude of different human health effects due to environmental stressors. The accounting and aggregating of these morbidity and mortality outcomes is key to support decision making and can be accomplished by different methods that we call human health metrics. This article attempts to answer two questions: Does it matter which metric is chosen? and What are the relevant characteristics of these metrics in environmental applications? Three metrics (quality adjusted life years (QALYs), disability adjusted life years (DALYs), and willingness to pay (WTP)) have been applied to the same diverse set of health effects due to environmental impacts. In this example, the choice of metric mattered for the ranking of these environmental impacts and it was found for this example that WTP was dominated by mortality outcomes. Further, QALYs and DALYs are sensitive to mild illnesses that affect large numbers of people and the severity of these mild illnesses are difficult to assess. Eight guiding questions are provided in order to help select human health metrics for environmental decision‐support tools. Since health metrics tend to follow the paradigm of utility maximization, these metrics may be supplemented with a semi‐quantitative discussion of distributional and ethical aspects. Finally, the magnitude of age‐dependent disutility due to mortality for both monetary and nonmonetary metrics may bear the largest practical relevance for future research.     

Modeling Growth and Reduction of Microorganisms in Foods as Functions of Temperature and Time

Food safety objectives (FSOs) are established in order to minimize the risk of foodborne illnesses to consumers, but these have not yet been incorporated into regulatory policy. An FSO states the maximum frequency and/or concentration of a microbiological hazard in a food at the time of consumption that provides an acceptable level of protection to the public and leads to a performance criterion for industry. However, in order to be implemented as a regulation, this criterion has to be achievable by the affected industry. In order to determine an FSO, the steps to produce and store that food need to be known, especially where they have an impact on contamination, growth, and destruction. This article uses existing models for growth of Listeria monocytogenes in conjunction with calculations of FSOs to approximate the outcome of more than one introduction of the foodborne organism throughout the food-processing path from the farm to the consumer. Most models for the growth and reduction of foodborne illnesses are logarithmic in nature, which fits the nature of the growth of microorganisms, spanning many orders of magnitude. However, these logarithmic models are normally limited to a single introduction step and a single reduction step. The model presented as part of this research addresses more than one introduction of food contamination, each of which can be separated by a substantial amount of time. The advantage of treating the problem this way is the accommodation of multiple introductions of foodborne pathogens over a range of time durations and conditions.     

Foodborne Exposure to Pesticides and Methylmercury in the United Arab Emirates

As part of a comprehensive environmental health strategic planning project initiated by the government of Abu Dhabi, we assessed potential dietary exposure in the United Arab Emirates (UAE) to methylmercury (in seafood) and pesticides (in fruits and vegetables) above international guideline levels. We present results for the UAE population by age, gender, and body mass index. Our results show very low daily risks of exposure to pesticides in fruits and vegetables at levels exceeding WHO guidelines even under the conservative assumption that no pesticides are removed during washing and food preparation. Thus, exposure to pesticides on fruits and vegetables does not appear to be a major public health concern in the UAE. The chances of exposure to methylmercury in seafood are much higher; our model estimates a mean 1 in 5 daily risk of exceeding the FAO/WHO provisional tolerable weekly intake. However, great caution should be used in interpreting these results, as we analyzed only the risks and not the substantial benefits of fish consumption. In fact, previous studies have demonstrated that exposure to the n‐3 polyunsaturated fatty acids in fish can increase IQ in developing children, and it can substantially decrease the risk in adults of coronary heart disease and stroke. Further research is warranted to compare the risk of Me‐Hg exposure from fish to the nutritional benefits of fish consumption in the UAE and to determine appropriate methods to communicate risk and benefit information to the UAE population.     

Risk Assessment for Invasive Species

Although estimates vary, there is a broad agreement that invasive species impose major costs on the U.S. economy, as well as posing risks to nonmarket environmental goods and services and to public health. The domestic effort to manage risks associated with invasive species is coordinated by the National Invasive Species Council (NISC), which is charged with developing a science-based process to evaluate risks associated with the introduction and spread of invasive species. Various international agreements have also elevated invasive species issues onto the international policy agenda. The World Trade Organization (WTO) Sanitary and Phytosanitary (SPS) Agreement establishes rights and obligations to adhere to the discipline of scientific risk assessment to ensure that SPS measures are applied only to the extent required to protect human, animal, and plant health, and do not constitute arbitrary or unjustifiable technical barriers to trade. Currently, however, the field of risk assessment for invasive species is in its infancy. Therefore, there is a pressing need to formulate scientifically sound methods and approaches in this emerging field, while acknowledging that the demand for situation-specific empirical evidence is likely to persistently outstrip supply. To begin addressing this need, the Society for Risk Analysis Ecological Risk Assessment Specialty Group and the Ecological Society of America Theoretical Ecology Section convened a joint workshop to provide independent scientific input into the formulation of methods and processes for risk assessment of invasive species to ensure that the analytic processes used domestically and internationally will be firmly rooted in sound scientific principles.     

Health data privacy

How can the tradition of patient-provider confidentiality be preserved and still meet the changing information needs of insurers, employers, public health agencies, policy analysts, and researchers? As countries grapple with the issue of a patient's right to medical record privacy, actions that the U.S. takes in this area will set precedents and have implications for nearly every health care electronic transaction. The Health Insurance Portability and Accountability Act requires the Secretary of Health and Human Services (HHS) to recommend standards for electronic financial and administrative transactions. The HHS focused on the confidentially of patient's health care information, guided by five principles in developing recommendations: (1) Boundaries; (2) Security; (3) Consumer Control; (4) Accountability; and (5) Public Responsibility.     

An overview of the Salmonella enteritidis risk assessment for shell eggs and egg products.

This article summarizes a quantitative microbial risk assessment designed to characterize the public health impact of consumption of shell eggs and egg products contaminated with Salmonella Enteritidis (SE). This risk assessment's objectives were to: (1) establish the baseline risk of foodborne illness from SE, (2) identify and evaluate potential risk mitigation strategies, and (3) identify data gaps related to future research efforts. The risk assessment model has five modules. The Egg Production module estimates the number of eggs produced that are SE-contaminated. Shell Egg Processing, Egg Products Processing, and Preparation & Consumption modules estimate the increase or decrease in the numbers of SE organisms in eggs or egg products as they pass through storage, transportation, processing, and preparation. A Public Health Outcomes module then calculates the incidence of illnesses and four clinical outcomes, as well as the cases of reactive arthritis associated with SE infection following consumption. The baseline model estimates an average production of 2.3 million SE-contaminated shell eggs/year of the estimated 69 billion produced annually and predicts an average of 661,633, human illnesses per year from consumption of these eggs. The model estimates approximately 94% of these cases recover without medical care, 5% visit a physician, an additional 0.5% are hospitalized, and 0.05% result in death. The contribution of SE from commercially pasteurized egg products was estimated to be negligible. Five mitigation scenarios were selected for comparison of their individual and combined effects on the number of human illnesses. Results suggest that mitigation in only one segment of the farm-to-table continuum will be less effective than several applied in different segments. Key data gaps and areas for future research include the epidemiology of SE on farms, the bacteriology of SE in eggs, human behavior in food handling and preparation, and human responses to SE exposure.     

The Supreme Court rules: the FDA and tobacco regulation

The United States Supreme Court recently ruled that the U.S. Food and Drug Administration does not have the legal authority to regulate tobacco products. This ruling significantly affects public health efforts to reduce tobacco addiction, especially among the nation's youth. This decision has broader health implications as well, since tobacco-related diseases are among many of the top ten leading causes of death. Paradoxically, this decision comes at a time where states are developing new health programs to address tobacco-related illnesses using funds from the landmark tobacco lawsuit.