Cost of Illness for Five Major Foodborne Illnesses and Sequelae in Sweden

Identification of cost-effective biosecurity measures to reduce Salmonella along the pork production chain

The continued occurrence of salmonellosis cases in Europe attributed to the consumption of pork products highlights the importance of identifying cost-effective interventions. Certain biosecurity measures (BSMs) may be effective in reducing the prevalence of specific pathogens along the pork production chain and their presence in food products. The objective of this study was to identify pathogen-specific, cost-effective BSMs to reduce Salmonella at different stages of the pork production chain in two European countries - Austria (AT) and the United Kingdom (UK). For this purpose, a cost-benefit analysis was conducted based on the epidemiological output of an established quantitative microbiological risk assessment that simulated the implementation effect of the BSMs based on their risk ratios. For each of the BSMs, the associated costs and benefits were assessed individually and country-specifically. For both AT and UK, nine different BSMs were evaluated assuming a countrywide implementation rate of 100%. The results showed that four BSMs were cost-effective (benefit-cost ratio > 1) for AT and five for the UK. The uncertainty regarding the cost-effectiveness of the BSMs resulted from the variability of individual risk ratios, and the variability of benefits associated with the implementation of the BSMs. The low number of cost-effective BSMs highlights the need for holistic risk-based models and economic assessments. To increase the willingness to implement BSMs and maximize the benefits for stakeholders, who carry the majority of the implementation costs, epidemiological assessments of BSM effectiveness should consider the impact on several relevant pathogens simultaneously.

Predicting Foodborne Disease Outbreaks with Food Safety Certifications: Econometric and Machine Learning Analyses

Since the late 1990s, food safety certification has emerged as a prominent and influential regulatory mechanism in both the private and public spheres of the contemporary agri-food system. Food safety standards protect consumers from foodborne illnesses and help producers avoid the massive economic losses associated with food safety breaches. We empirically examine the relationship between foodborne disease outbreaks and certification adoption by utilizing the data on food safety certification adoption in the United States and Europe from 2015 through 2020. In our regression models, food safety certification along with select economic variables such as gross domestic product are used to explain the number of illnesses caused by foodborne disease outbreaks. For the United States at the state level, we found that certifications to SQF, PrimusGFS, BRC, or FSSC 22000 are negatively associated with the number of foodborne illnesses. For the case of Europe at the country level, certifications to ISO 22000 or FSSC 22000 are negatively associated with the number of foodborne illnesses. We then proceed to use machine learning techniques to examine how well we can use food safety certification data to predict foodborne disease outbreaks. Applying several algorithms (ordinary least squares, multinomial, decision tree, and random forest) to the U.S. data, we found that our models with food safety certification adoption can predict the number of U.S. foodborne illnesses or deaths with a relatively high degree of precision (testing accuracy at around 70% or better). Feature importance analysis allows us to inspect the relative importance of each explanatory variable (or feature) for making accurate predictions of the illness or death numbers. Through ranking the importance of explanatory variables, our study reveals that certification information could be the second most important variable (after gross domestic product) contributing to explain foodborne disease outbreaks.

Health care utilizations and costs of Campylobacter enteritis in Germany: A claims data analysis

OBJECTIVE

The number of reported cases of Campylobacter enteritis (CE) remains on a high level in many parts of the world. The aim of this study was to analyze the health care utilizations and direct and indirect costs of CE and sequelae of patients insured by a large health insurance with 26 million members in Germany.

METHODS

Claims data of insurants with at least one CE diagnosis in 2017 (n = 13,150) were provided, of which 9,945 were included in the analysis of health care utilizations and costs. If medical services were not diagnosis-linked, CE-associated costs were estimated in comparison to up to three healthy controls per CE patient. Indirect costs were calculated by multiplying the work incapacities by the average labor costs. Total costs of CE in Germany were extrapolated by including all officially reported CE cases in 2017 using Monte Carlo simulations.

RESULTS

Insurants showed a lower rate of 56 CE diagnoses per 100,000 than German surveillance data for 2017, but with a similar age, gender and regional distribution. Of those CE cases, 6.3% developed post-infectious reactive arthritis, Guillain-Barré syndrome (GBS), inflammatory bowel disease (IBD) and/or irritable bowel syndrome (IBS). Health care utilizations differed depending on CE severity, age and gender. Average CE-specific costs per patient receiving outpatient care were € 524 (95% CI 495-560) over a 12-month period, whereas costs per hospitalized CE case amounted to € 2,830 (2,769-2,905). The analyzed partial costs of sequelae ranged between € 221 (IBS) and € 22,721 (GBS) per patient per 12 months. Total costs of CE and sequelae extrapolated to Germany 2017 ranged between € 74.25 and € 95.19 million, of which 10-30% were due to sequelae.

CONCLUSION

CE is associated with a substantial economic burden in Germany, also due to care-intensive long-lasting sequelae. However, uncertainties remain as to the causal relationship of IBD and IBS after CE.

One Health surveillance-A cross-sectoral detection, characterization, and notification of foodborne pathogens

Introduction

Several Proficiency Test (PT) or External Quality Assessment (EQA) schemes are currently available for assessing the ability of laboratories to detect and characterize enteropathogenic bacteria, but they are usually targeting one sector, covering either public health, food safety or animal health. In addition to sector-specific PTs/EQAs for detection, cross-sectoral panels would be useful for assessment of the capacity to detect and characterize foodborne pathogens in a One Health (OH) perspective and further improving food safety and interpretation of cross-sectoral surveillance data. The aims of the study were to assess the cross-sectoral capability of European public health, animal health and food safety laboratories to detect, characterize and notify findings of the foodborne pathogens Campylobacter spp., Salmonella spp. and Yersinia enterocolitica, and to develop recommendations for future cross-sectoral PTs and EQAs within OH. The PT/EQA scheme developed within this study consisted of a test panel of five samples, designed to represent a theoretical outbreak scenario.

Methods

A total of 15 laboratories from animal health, public health and food safety sectors were enrolled in eight countries: Denmark, France, Italy, the Netherlands, Poland, Spain, Sweden, and the United Kingdom. The laboratories analyzed the samples according to the methods used in the laboratory and reported the target organisms at species level, and if applicable, serovar for Salmonella and bioserotype for Yersinia.

Results

All 15 laboratories analyzed the samples for Salmonella, 13 for Campylobacter and 11 for Yersinia. Analytical errors were predominately false negative results. One sample (S. Stockholm and Y. enterocolitica O:3/BT4) with lower concentrations of target organisms was especially challenging, resulting in six out of seven false negative results. These findings were associated with laboratories using smaller sample sizes and not using enrichment methods. Detection of Salmonella was most commonly mandatory to notify within the three sectors in the eight countries participating in the pilot whereas findings of Campylobacter and Y. enterocolitica were notifiable from human samples, but less commonly from animal and food samples.

Discussion

The results of the pilot PT/EQA conducted in this study confirmed the possibility to apply a cross-sectoral approach for assessment of the joint OH capacity to detect and characterize foodborne pathogens.

Epidemiology and Economic Burden of an Outbreak of Cyclopeptide-Containing Mushroom Poisoning in the West of Iran

Little evidence is available on the epidemiological and economical dimensions of certain foodborne diseases such as wild mushroom poisoning. This study aimed to investigate the epidemiology and estimate the costs of poisoning with cyclopeptide-containing mushrooms in Kermanshah province in 2018. In this study, poisoning was investigated in different subgroups. The cost of illness method with a bottom-up approach was used to estimate the poisoning costs. Both direct and indirect costs of the poisoning were included in the analysis. The perspective of the study was society. Required data were obtained from the medical records of Imam Khomeini hospital and completed through a line survey with the patients. Two hundred eighty-three patients were poisoned in Kermanshah due to poisoning with cyclopeptide-containing mushrooms. Of 283 patients, 143 (50.53%) were men and 59.01% of patients were rural residents. About 43% of admissions were out-patient cases and ~40% of patients were hospitalized within 1-3 days. Also, eight patients were pronounced dead in the area. The total cost of poisoning with cyclopeptide-containing mushrooms in Kermanshah province was $ 1,259,349.26. Of that, $ 69,281.65 was related to direct medical costs and $ 10,727.23 was direct non-medical costs. The indirect costs of death were estimated to be $ 1,125,829.7. The current study revealed that there is a significant financial burden due to cyclopeptide-containing mushrooms on patients, the health system, and society as a whole. Further studies are recommended to clarify the epidemiological and economic burden of foodborne illnesses related to wild mushroom poisonings. Sharing the outputs with health authorities, and informing the general public are warranted to reduce the burden of such diseases.

Estimating the Number of Illnesses Caused by Agents Transmitted Commonly Through Food: A Scoping Review

Estimates of the overall human health impact of agents transmitted commonly through food complement surveillance and help guide food safety interventions and regulatory initiatives. The purpose of this scoping review was to summarize the methods and reporting practices used in studies that estimate the total number of illnesses caused by these agents. We identified and included 43 studies published from January 1, 1995, to December 31, 2019, by searching PubMed and screening selected articles for other relevant publications. Selected articles presented original estimates of the number of illnesses caused by ≥1 agent transmitted commonly through food. The number of agents (species or subspecies for pathogens) included in each study ranged from 1 to 31 (median: 4.5; mean: 9.2). Of the 40 agents assessed across the 43 studies, the most common agent was Salmonella (36; 84% of studies), followed by Campylobacter (33; 77%), Shiga toxin-producing Escherichia coli (25; 58%), and norovirus (20; 47%). Investigators used a variety of data sources and methods that could be grouped into four distinct estimation approaches-direct, surveillance data scaled-up, syndrome or population scaled-down, and inferred. Based on our review, we propose four recommendations to improve the interpretability, comparability, and reproducibility of studies that estimate the number of illnesses caused by agents transmitted commonly through food. These include providing an assessment of statistical and nonstatistical uncertainty, providing a ranking of estimates by agent, including uncertainties; describing the rationale used to select agents and data sources; and publishing raw data and models, along with clear, detailed methods. These recommendations could lead to better decision-making about food safety policies. Although these recommendations have been made in the context of illness estimation for agents transmitted commonly through food, they also apply to estimates of other health outcomes and conditions.

Single Nanowire Gas Sensor Able to Distinguish Fish and Meat and Evaluate Their Degree of Freshness

A non-invasive, small, and fast device is needed for food freshness monitoring, as current techniques do not meet these criteria. In this study, a resistive sensor composed of a single semiconductor nanowire was used at different temperatures, combining the responses and processing them with multivariate statistical analysis techniques. The sensor, very sensitive to ammonia and total volatile basic nitrogen, proved to be able to distinguish samples of fish (marble trout, Salmo trutta marmoratus) and meat (pork, Sus scrofa domesticus), both stored at room temperature and 4 °C in the refrigerator. Once separated, the fish and meat samples were classified by the degree of freshness/degradation with two different classifiers. The sensor classified the samples (trout and pork) correctly in 95.2% of cases. The degree of freshness was correctly assessed in 90.5% of cases. Considering only the errors with repercussions (when a fresh sample was evaluated as degraded, or a degraded sample was evaluated as edible) the accuracy increased to 95.2%. Considering the size (less than a square millimeter) and the speed (less than a minute), this type of sensor could be used to monitor food production and distribution chains.

Enteric Pathogens and Reactive Arthritis: Systematic Review and Meta-Analyses of Pathogen-Associated Reactive Arthritis

The objective of this systematic review and meta-analysis was to estimate the proportion of postinfectious reactive arthritis (ReA) after bacterial enteric infection from one of four selected pathogens. We collected studies from PubMed, Web of Science, and Embase, which assessed the proportion of postinfectious ReA published from January 1, 2000 to April 1, 2018. Papers were screened independently by title, abstract, and full text; papers in English, Spanish, and Portuguese utilizing a case-control (CC) or cohort study design, with a laboratory confirmed or probable acute bacterial enteric infection and subsequent ReA, were included. The proportion of ReA cases was pooled between and across pathogens. Factors that can induce study heterogeneity were explored using univariate meta-regression, including region, sample size, study design, and ReA case ascertainment. Twenty-four articles were included in the final review. The estimated percentage of cases across studies describing Campylobacter-associated ReA (n = 11) was 1.71 (95% confidence interval [CI] 0.49-5.84%); Salmonella (n = 17) was 3.9 (95% CI 1.6-9.1%); Shigella (n = 6) was 1.0 (95% CI 0.2-4.9%); and Yersinia (n = 7) was 3.4 (95% CI 0.8-13.7%). Combining all four pathogens, the estimated percentage of cases that developed ReA was 2.6 (95% CI 1.5-4.7%). Due to high heterogeneity reflected by high I² values, results should be interpreted with caution. However, the pooled proportion developing ReA from studies with sample sizes (N) <1000 were higher compared with N > 1000 (6% vs. 0.3%), retrospective cohort studies were lower (1.1%) compared with CC or prospective cohorts (6.8% and 5.9%, respectively), and those where ReA cases are identified through medical record review were lower (0.3%) than those identified by a specialist (3.9%) or self-report (12%). The estimated percentage of people who developed ReA after infection with Campylobacter, Salmonella, Shigella, or Yersinia is relatively low (2.6). In the United States, this estimate would result in 84,480 new cases of ReA annually.

Quantitative Assessment of Trout Fish Spoilage with a Single Nanowire Gas Sensor in a Thermal Gradient

The response of a single tin oxide nanowire was collected at different temperatures to create a virtual array of sensors working as a nano-electronic nose. The single nanowire, acting as a chemiresistor, was first tested with pure ammonia and then used to determine the freshness status of trout fish (Oncorhynchus mykiss) in a rapid and non-invasive way. The gas sensor reacts to total volatile basic nitrogen, detecting the freshness status of the fish samples in less than 30 s. The sensor response at different temperatures correlates well with the total viable count (TVC), demonstrating that it is a good (albeit indirect) way of measuring the bacterial population in the sample. The nano-electronic nose is not only able to classify the samples according to their degree of freshness but also to quantitatively estimate the concentration of microorganisms present. The system was tested with samples stored at different temperatures and classified them perfectly (100%), estimating their log(TVC) with an error lower than 5%.

Salmonella, Food Safety and Food Handling Practices

Salmonellosis is the second most reported gastrointestinal disorder in the EU resulting from the consumption of Salmonella-contaminated foods. Symptoms include gastroenteritis, abdominal cramps, bloody diarrhoea, fever, myalgia, headache, nausea and vomiting. In 2018, Salmonella accounted for more than half of the numbers of foodborne outbreak illnesses reported in the EU. Salmonella contamination is mostly associated with produce such as poultry, cattle and their feeds but other products such as dried foods, infant formula, fruit and vegetable products and pets have become important. Efforts aimed at controlling Salmonella are being made. For example, legislation and measures put in place reduced the number of hospitalizations between 2014 and 2015. However, the number of hospitalizations started to increase in 2016. This calls for more stringent controls at the level of government and the private sector. Food handlers of "meat processing" and "Ready to Eat" foods play a crucial role in the spread of Salmonella. This review presents an updated overview of the global epidemiology, the relevance of official control, the disease associated with food handlers and the importance of food safety concerning salmonellosis.

Detection of Mackerel Fish Spoilage with a Gas Sensor Based on One Single SnO2 Nanowire

A chemosensor consisting of one single tin oxide nanowire is used to determine the freshness status of mackerel fish (Scomber scombrus) in a quick and non-invasive way. The tiny chemoresistive sensor is first tested with pure ammonia and then used to measure the total volatile basic nitrogen from different samples of fish at different degrees of freshness. The sensor has proved capable of determining the freshness of a sample in few seconds compared to traditional methods such as microbial count and chromatography, which take hours. The sensor response is well correlated with the total viable count (TVC), proving that the total volatile basic nitrogen is a good way to quickly test the bacterial population in the sample. After calibrating the sensor (following the degradation of the fish during almost two days), it has been tested with random double blind samples, proving that it can well discriminate the degree of freshness of the fish preserved at different temperatures.

Staying out or Going in? The Interplay between Type 3 and Type 5 Secretion Systems in Adhesion and Invasion of Enterobacterial Pathogens

Enteric pathogens rely on a variety of toxins, adhesins and other virulence factors to cause infections. Some of the best studied pathogens belong to the Enterobacterales order; these include enteropathogenic and enterohemorrhagic Escherichia coli, Shigella spp., and the enteropathogenic Yersiniae. The pathogenesis of these organisms involves two different secretion systems, a type 3 secretion system (T3SS) and type 5 secretion systems (T5SSs). The T3SS forms a syringe-like structure spanning both bacterial membranes and the host cell plasma membrane that translocates toxic effector proteins into the cytoplasm of the host cell. T5SSs are also known as autotransporters, and they export part of their own polypeptide to the bacterial cell surface where it exerts its function, such as adhesion to host cell receptors. During infection with these enteropathogens, the T3SS and T5SS act in concert to bring about rearrangements of the host cell cytoskeleton, either to invade the cell, confer intracellular motility, evade phagocytosis or produce novel structures to shelter the bacteria. Thus, in these bacteria, not only the T3SS effectors but also T5SS proteins could be considered "cytoskeletoxins" that bring about profound alterations in host cell cytoskeletal dynamics and lead to pathogenic outcomes.

Cost of Salmonella Infections in Australia, 2015

Gastroenteritis caused from infections with Salmonella enterica (salmonellosis) causes significant morbidity in Australia. In addition to acute gastroenteritis, approximately 8.8% of people develop irritable bowel syndrome (IBS) and 8.5% of people develop reactive arthritis (ReA). We estimated the economic cost of salmonellosis and associated sequel illnesses in Australia in a typical year circa 2015. We estimated incidence, hospitalizations, other health care usage, absenteeism, and premature mortality for four age groups using a variety of complementary data sets. We calculated direct costs (health care) and indirect costs (lost productivity and premature mortality) by using Monte Carlo simulation to estimate 90% credible intervals (CrI) around our point estimates. We estimated that 90,833 cases, 4,312 hospitalizations, and 19 deaths occurred from salmonellosis in Australia circa 2015 at a direct cost of AUD 23.8 million (90% CrI, 19.3 to 28.9 million) and a total cost of AUD 124.4 million (90% CrI, 107.4 to 143.1 million). When IBS and ReA were included, the estimated direct cost was 35.7 million (90% CrI, 29.9 to 42.7 million) and the total cost was AUD 146.8 million (90% CrI, 127.8 to 167.9 million). Foodborne infections were responsible for AUD 88.9 million (90% CrI, 63.9 to 112.4 million) from acute salmonellosis and AUD 104.8 million (90% CrI, 75.5 to 132.3 million) when IBS and ReA were included. Targeted interventions to prevent illness could considerably reduce costs and societal impact from Salmonella infections and sequel illnesses in Australia.