The cost of Norovirus in Germany

We estimated numbers of hospitalizations for norovirus gastroenteritis (NGE) and associated medical costs in Germany, where norovirus testing is high because reimbursement is affected. We extracted aggregate data for patients hospitalized with a primary or secondary code from the International Classification of Diseases, 10th Revision (ICD-10), NGE diagnosis during 2007–2012 from the German Federal Statistics Office.

We assessed reliability of the coding system in patient records from a large academic hospital. Approximately 53,000–90,000 NGE hospitalizations occurred annually in Germany (21,000–33,000 with primary and 32,000–57,000 with secondary ICD-10–coded NGE diagnoses). Rates of hospitalization with NGE as primary diagnosis were highest in children <2 years of age; rates of hospitalization with NGE as secondary diagnosis were highest in adults >85 years of age. The average annual reimbursed direct medical cost of NGE hospitalizations was €31–43 million. Among patients with a NGE ICD-10 code, 87.6% had positive norovirus laboratory results.

Norovirus Gastroenteritis among Hospitalized Patients, Germany, 2007–2012

Kowalzik, F., Binder, H., Zöller, D., Riera-Montes, M., Clemens, R., Verstraeten, T….Zepp, F. (2018). Norovirus Gastroenteritis among Hospitalized Patients, Germany, 2007–2012. Emerging Infectious Diseases, 24(11), 2021-2028. https://dx.doi.org/10.3201/eid2411.170820.

https://wwwnc.cdc.gov/eid/article/24/11/17-0820_article

A foodborne illness outbreak could cost a restaurant millions, study suggests

A single foodborne outbreak could cost a restaurant millions of dollars in lost revenue, fines, lawsuits, legal fees, insurance premium increases, inspection costs and staff retraining, a new study from researchers at the Johns Hopkins Bloomberg School of Public Health suggests.

The findings, which will be published online on Apr. 16 in the journal Public Health Reports, are based on computer simulations that suggest a foodborne illness outbreak can have large, reverberating consequences regardless of the size of the restaurant and outbreak. According to the model, a fast food restaurant could incur anywhere from $4,000 for a single outbreak in which 5 people get sick (when there is no loss in revenue and no lawsuits, legal fees, or fines are incurred) to $1.9 million for a single outbreak in which 250 people get sick (when restaurants loose revenue and incur lawsuits, legal fees, and fines).

Americans eat out approximately five times per week, according to the National Restaurant Association. The Centers for Disease Control and Prevention (CDC) estimates that approximately 48 million people get sick, 128,000 are hospitalized and 3,000 die each year due to food-related illnesses, which are often referred to as food poisoning.

For the study, the researchers developed a computational simulation model to represent a single outbreak of a particular pathogen occurring at a restaurant. The model broke down results for four restaurant types: fast food, fast casual, casual and fine dining under various parameters (e.g., outbreak size, pathogen, and scenarios).

The model estimated costs of 15 foodborne pathogens that caused outbreaks in restaurants from 2010 – 2015 as reported by the CDC. Examples of the pathogens incorporated in the model were listeria, norovirus, hepatitis A, E. coli and salmonella. The model ran several different scenarios to determine the impact level ranging from smaller outbreaks that may incur few costs (i.e., no lawsuits and legal fees or fines) to larger outbreaks that incur a high amount of lawsuits and legal fees.

“Many restaurants may not realize how much even just a single foodborne illness outbreak can cost them and affect their bottom line,” says Bruce Y. Lee, MD, MBA, executive director of the Global Obesity Prevention Center (GOPC) at the Bloomberg School. “Paying for and implementing proper infection control measures should be viewed as an investment to avoid these costs which can top a million dollars. Knowing these costs can help restaurants know how much to invest in such safety measures.”

The research team found that a single outbreak of listeria in fast food and casual style restaurants could cost upwards of $2.5 million in meals lost per illness, lawsuits, legal fees, fines and higher insurance premiums for a 250-person outbreak. When looking at the same circumstances for fine dining restaurants, $2.6 million in costs were incurred. The subsequent costs of outbreaks can be major setbacks for restaurants and are sometime irreversible. For example, Chi-Chi’s restaurant went bankrupt and closed their doors in the U.S. and Canada permanently due to a hepatitis A outbreak in 2003. In the past decade, several national restaurant chains have lost significant business due to food-illness outbreaks.

“Even a small outbreak involving five to 10 people can have large ramifications for a restaurant,” says Sarah M. Bartsch, research associate at the Global Obesity Prevention Center and lead author of the study. “Many prevention measures can be simple, like implement adequate food safety staff training for all restaurant employees and apply sufficient sick leave policies, and can potentially avoid substantial costs in the event of an outbreak.”

NZ campy outbreak cost $21m

In Aug. 2016, some 5,500 people in a New Zealand town of 14,000 were sickened with Campylobacter linked to the water supply and three died.

Didn’t chlorinate.

Eric Frykberg of RadioNZ reports the NZ Ministry of Health has found Havelock North’s water contamination cost about $21 million – with residents the worst affected.

The campylobacter infection hit the town last August and afflicted more than 5,000 people with illness, filling the hospital and potentially contributing to three deaths.

The investigators measured the next best thing that people could have been doing if they had not been sick. That and the value of direct costs added up to the total figure of $21,029,288.

A report commissioned by the ministry said some 5088 households were affected by the crisis, and the cost to each household was about $2440.

Those costs included the cost of people getting sick and being unable to go to work or school or carry out other tasks.

Some were unable to look after their children, while others had to drive all over town to visit doctors or to get fresh water or other supplies.

They also had to do far more laundry and cleaning.

This left the households to foot a bill of more than $12,420,000 making up the majority of all costs from the crisis.

The report also said not all consequences of the outbreak could be quantified in monetary terms, with personal stress, loss of public faith in the water supply, and “scarring” of the community adding to the societal bill.

The report said about 25 percent of the population of Havelock North was aged over 65 based on the 2013 Census, and the town also had a large number of school aged children.

The public health cost of a hepatitis A outbreak: scallops edition

A recent twitter exchange about corporate food safety folks really becoming compliance teams highlights that all this food safety stuff is nestled somewhere in a web of risk, cost and benefit. Risk and benefit come down to public health and business risk metrics – which can be fraught with limitations and assumptions.screen-shot-2016-11-04-at-7-11-13-am

Risk-based decision making is the mantra in food safety. Picking out an intervention is a starts with a numbers game: calculating the likelihood of an action (like handwashing) and matching that with the prevalence of a pathogen in the system. This is the stuff that gets the math nerds like Schaffner excited (me too). Businesses are faced with risk, cost and benefit decisions daily.

Food safety teams that focus just on compliance are trusting that the compliance folks got the science and risk correct. Sometimes they do. But lawmaking is slow.

The cost part of the equation somewhat straight forward.

One cost that’s been debated in food service for over twenty years is whether or not employers or public health folks should require food handlers to be vaccinated for hepatitis A. Jacobs and colleagues arrived at the conclusion that the public health benefit of vaccinating for hep A doesn’t equal the costs – but doesn’t factor in all the bad publicity, hassle and incident management costs.

Or costs to the public health system. According to KHON2 300+ cases of hepatitis A is costing hundreds of thousands of public health dollars.

The Hawaii Department of Health says it’s spent approximately $336,100 to investigate and respond to the hepatitis A outbreak.

images-1Here’s how it breaks down: $304,600 were spent on normal staff work hours, and an estimated $19,750 went to pay for 300 hours of overtime work.

The rest went to pay for vaccines and lab specimen shipments to the Centers for Disease Control and Prevention, but the health department tells us that was covered by federal grant funds.

It took a lot of work for health officials just to pinpoint the source of the outbreak, including an online survey, numerous interviews with people, and visits to businesses.

Although officials identified the source — imported frozen scallops — they’re still not done with this outbreak. They’re now looking into a hepatitis-A-related death.

“The woman was in and out of the hospital really since she became ill in July, and so there were times where she needed a liver transplant,” said foodborne illness attorney Bill Marler. “She sort of seemed to rally. She got to go home for a little while, and then she was back in the hospital with complications.”

Throwing stones from Haaarvaaard: The cost of a sick customer

Harvard picked an easy target, offering its management insight to Chipotle, but I’ve yet to see a paper about how the venerable Haaarvaaard Faculty Club managed to sicken patrons not once, but twice with Norovirus in 2010.

simpsons.harvardAccording to PR from Haaarvaaard, Chipotle has seen its shares tumble and recently reported its first-ever quarterly loss after the incident, which began in October when more than 50 people in 11 states were sickened by an initial E. coli outbreak.

The chain restaurant, which uses the tagline “Food with Integrity,” has prided itself on avoiding artificial ingredients, opting instead to use a relatively short supply chain of local growers for many of its ingredients.

That strategy just might have been part of its problem, says John A. Quelch, the Charles Edward Wilson Professor of Business Administration at Harvard Business School and Professor in Health Policy and Management at the Harvard T.H. Chan School of Public Health.

Quelch, who teaches a course to Harvard business and public health students called Consumers, Corporations and Public Health, says food safety is more challenging than ever for three reasons:

  • the globalization of the food business;
  • global food safety standards are lacking; and,
  • food safety problems can be quite costly.

Thanks for the insight. Back to hockey.

I love it when Batz talks Swedish about food safety priority setting and ranking

In Sweden, acute gastrointestinal illness (AGI) incidence, severity, impact on productivity, related healthcare usage and associated costs are not ascertained.

Michael Batz RZ ED PART 2We measured these in 2013–2014 using a population-based cohort reporting weekly. We defined AGI as ≥3 episodes of loose stools or vomiting/24 h; or loose stools or vomiting with ≥2 other gastrointestinal symptoms. After each AGI episode, we collected information about perceived severity, healthcare use and absenteeism. We calculated incidence rates, AGI absenteeism and costs comprising direct healthcare costs and productivity loss due to work/school absenteeism. A total of 3241 participants reported 1696 AGI episodes [incidence 360/1000 person-years, 95% confidence interval (CI) 326–395; highest in the <5 years age group]. In the <5 years age group, 31% of episodes were perceived as mild, 61% as moderate and 8% as severe; 9·4% led to primary-care consultations, and 1·4% to hospital admissions. In the ≥5 years age group, 18% of episodes were perceived as mild, 64% as moderate and 18% as severe; 6·4% led to primary-care consultations, and 1·9% to hospital admissions. AGI caused 8 891 000 days of absenteeism (95% CI 6 009 000–12 780 000). AGI cost €1 005 885 000 (95% CI 754 309 000–1 257 195 000) nationally for the year.

In Sweden, a minority of cases perceive AGI as a mild illness. AGI is a burden on the healthcare system and causes productivity loss, with high costs. Countries may consider these estimates when prioritizing health interventions.

Quantifying the incidence and cost of acute gastrointestinal illness in Sweden, 2013–2014

Epidemiology and Infection [early view]

Edelstein, H. Merk, C. Deogan, A. Carnahan and A. Wallensten

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10231889&fileId=S0950268816000467

Cost of Salmonella

Hospitalized salmonellosis patients with concurrent chronic conditions may be at increased risk for adverse outcomes, increasing the costs associated with hospitalization. Identifying important modifiable risk factors for this predominantly foodborne illness may assist hospitals, physicians, and public health authorities to improve management of these patients.

salm.hospital.nov.15The objectives of this study were to (1) quantify the burden of salmonellosis hospitalizations in the United States, (2) describe hospitalization characteristics among salmonellosis patients with concurrent chronic conditions, and (3) examine the relationships between salmonellosis and comorbidities by four hospital-related outcomes.

A retrospective analysis of salmonellosis discharges was conducted using the Agency for Healthcare Research and Quality’s Nationwide Inpatient Sample for 2011. A supplemental trend analysis was performed for the period 2000–2011. Hospitalization characteristics were examined using multivariable regression modeling, with a focus on four outcome measures: in-hospital death, total amount billed by hospitals for services, length of stay, and disease severity.

In 2011, there were 11,032 total salmonellosis diagnoses; 7496 were listed as the primary diagnosis, with 86 deaths (case-fatality rate = 1.2%). Multivariable regression analyses revealed a greater number of chronic conditions (≥4) among salmonellosis patients was associated with higher mean total amount billed by hospitals for services, longer length of stay, and greater disease severity (p ≤ 0.05). From 2000 to 2011, hospital discharges for salmonellosis increased by 27.2%, and the mean total amount billed by hospitals increased nearly threefold: $9,777 (2000) to $29,690 (2011).

Observed increases in hospitalizations indicate the burden of salmonellosis remains substantial in the United States. The positive association between increased number of chronic conditions and the four hospital-related outcomes affirms the need for continual healthcare and public health investments to prevent and control this disease in vulnerable groups.

 Salmonellosis Hospitalizations in the United States: Associated Chronic Conditions, Costs, and Hospital Outcomes, 2011, Trends 2000–2011

Foodborne Pathogens and Disease [ahead of print]

Cummings Patricia L., Kuo Tony, Javanbakht Marjan, Shafir Shira, Wang May, and Sorvillo Frank.

http://online.liebertpub.com/doi/abs/10.1089/fpd.2015.1969

UK supermarket chicken price war ‘putting health at risk’

When I showed up in Australia and started shopping at my local stores – as you do without a car – I noticed the whole chickens were leaking all kinds of bacterial crap.

moneyI spoke with the manager and said, in the U.S., they have additional plastic bags in the meat section and antibacterial wipes.

He said, that’s a great idea, I’ll bring it up at our fortnightly food safety meeting.

The company decided not to do anything because the wipes would cost half-a-cent each.

Other customers I’ve chatted with say they grab a plastic bag from the produce section to further enclose their chicken.

UK professor, Chris Elliott, who led the official inquiry into the horsemeat scandal, says supermarkets are reluctant to bring in changes that could reduce potentially fatal infections from chicken because of the cost.

Food safety versus economics.

Cost of foodborne illness varies by US state

An understanding of the costs associated with foodborne illnesses is important to policy makers for prioritizing resources and assessing whether proposed interventions improve social welfare.

sorenne.moneyAt the national level, measured costs have been used by federal food safety regulatory agencies in regulatory impact analyses. However, when costs differ across states, use of national cost-of-illness values for state-based interventions will lead to biased estimates of intervention effectiveness.

In this study, the costs of foodborne illness at the state level were estimated. Using a more conservative economic model, the average cost per case ranged from $888 (90% credible interval [CI], $537 to $1,419) in West Virginia to $1,766 (90% CI, $1,231 to $2,588) in the District of Columbia. A less conservative model generated average costs per case of $1,505 (90% CI, $557 to $2,836) in Kentucky to $2,591 (90% CI, $857 to $5,134) in Maryland. Aggregated across the states, the average national cost of foodborne illness was estimated as $55.5 billion (90% CI, $33.9 to $83.3 billion) using the conservative model and $93.2 billion (90% CI, $33.0 to $176.3 billion) using the enhanced model.

State estimates for the annual cost of foodborne illness

Journal of Food Protection®, Number 6, June 2015, pp. 1064-1243, pp. 1064-1071(8), DOI: http://dx.doi.org/10.4315/0362-028X.JFP-14-505

Scharff, Robert L.

http://www.ingentaconnect.com/content/iafp/jfp/2015/00000078/00000006/art00001

Foodborne Illness: Consumer Costs, Consequences, and Choices (via The Abstract)

I’m collaborating with Matt Shipman, public information officer at NC State University and curator of The Abstract, on a set of food safety-related posts from other NCSU folks as we roll toward WHO’s World Health Day on April 7– which is focused this year on food safety. Here’s a post on consumer purchasing issues as they relate to food safety from my friend Kathryn Boys, an assistant professor of agricultural and resource economics at NC State.

Changes to our food system have increased the availability and variety of foods for U.S. consumers, but these changes have also introduced food safety challenges that can have significant impacts on human health and the economy. Researchers are working to develop new food safety tools – and in the meantime there are actions consumers can take to lower their risk of foodborne illness.Boys-Food-Safety-HEADER-848x477

The U.S. Centers for Disease Control and Prevention (CDC) estimates that 48 million instances of foodborne illnesses occur annually in the U.S., resulting in 128,000 hospitalizations and 3,000 deaths. The value of medical costs, productivity losses, long-term mental and other health impacts, and the costs of premature deaths stemming from these events is substantial. The fourteen pathogens that account for a majority of U.S. foodborne illness have recently been estimated to cost the U.S. economy $14 billion and cause a loss of 61,000 quality-adjusted life years annually.

The potential for a specific foodborne illness outbreak to have a broad and significant impact on human health and the economy is compounded by the integration and globalization of food supply chains. Historically, because of perishability and the fact that produce was predominantly consumed in its raw form, incidents involving produce contaminated in a farm setting would have only affected consumers geographically near the farm. Today, through improved transportation and logistics networks and increased processing, that same produce has the potential to be used in a wider variety of products and affect consumers far from where it was grown.

In addition, identifying the source of contamination may be challenging and time consuming for food wholesalers and other distributors who aggregate products from across many suppliers and who have not implemented traceability practices. And that delay in tracing the source of the contamination means there is more time in which additional consumers may become sick.

When Illness Strikes: Impact on Individual Consumers

A majority of consumers who become ill due to foodborne illness recover at home or with minor medical assistance. In cases of severe illness that can be attributed to either food prepared outside of their home (i.e., restaurants), or contaminated prior to entering their home, consumers may pursue legal remedy for their illness. Information on the number or outcomes of cases settled out of court is not available. We do have some insight, however, of food safety cases settled through jury trials.

Buzby, et al., analyzed federal jury trials (1988-1997) for foodborne pathogens to determine which factors of the incident/case most influenced the trial outcomes. These authors found that 31.4 percent of cases were won by plaintiffs, and juries awarded a median of $25,560 (ranging from $0 to $2.37 million in 1998 dollars). Demographic characteristics of the plaintiff, the ability of plaintiffs to link their illness to a specific pathogen, and the severity of the health impact resulted in higher awards.

Given increasing public and media attention to foodborne illness, continued integration of food supply networks, and improved traceability systems, it is likely that both the number of cases and the amount of these awards will increase over time. I am currently working with collaborators at Virginia Tech and the USDA Economic Research Service to examine this issue.

Foodborne Illness: Preventative Market Measures

Most U.S. consumers have faith in the safety of food supply chain. In general, consumers expect their products to be free from dangerous levels of contamination and to be efficiently recalled if there is a problem. However, the incidence of foodborne illness suggests that problems remain.

Higher levels of food safety can be attained for most food products, lowering the risk of purchasing a contaminated product. But increased food safety comes at a cost.

Research has explored how much more consumers are willing to pay for higher levels of food safety.

In general, findings indicate that U.S. consumers are willing to pay more for higher levels of safety due to risk from microbial, chemical or physical (e.g., metal) contamination. How much more, however, has been found to vary considerably depending on the research setting, the particular food products being studied, the extent of risk reduction, and the research participants’ adherence to safe food handling practices, perception of risk, and demographic characteristics.  The same is true for perceived threats to food safety from other sources.

Consumers concerned about pesticide residues or genetic modification, for example, are willing to pay higher prices for organic and non-GMO foods. Consumer willingness to pay to avoid other food technologies, such as artificial colorants, fruit-ripening technologies, growth hormones and other growth promotants, and nanotechnology (among many others) has been summarized by Lusk, et al.

Consumers interested in decreasing their risk of foodborne illness have the option of buying products from companies with good food safety records, and to keep abreast of product recalls and safety alerts. Once food has entered the home, the food handling and sanitation practices that consumers can take to limit their risk of foodborne illness are generally well known. Information about safe food handling techniques can be found at http://www.foodsafety.gov/index.html.

In the future, additional tools are also likely to be available to consumers. By way of example, food producers often signal the presence (or absence) of specific food attributes through a growing array of food certification and labeling schemes. While at present, there is no label to identify products with higher levels of microbial food safety, it is possible that one may emerge. In addition, human vaccines are currently under development to protect against illness due to Escherichia coli, Salmonella, and Campylobacter. These and other tools are likely to significantly change the food safety market and policy landscape in coming years.