The MSMO algorithm

The disease burden

Estimating the importance of foodborne diseases in the total disease burden of a population is difficult. The Danish Veterinary and Food Administration (16) listed common food-related problems and their incidence in the general popu-lation. Table 2.3 shows some of these and also shows the agency’s hazard rating, indicating the need for action. Other factors may also be significant, such as foodborne viruses, heavy metals and possibly food additives. For example, phe-nylalanine, found in some artificial sweeteners, is a hazard for the estimated one in 10 000 people born with the enzyme disorder phenylketonuria.

More detailed work has been undertaken using a measure of the number of years of healthy life lost due to disease: DALYs (see Chapter 1, pp. 7–8). In the EU, diarrhoeal disease accounts for barely 0.2% of the total DALYs lost, according to estimates made by the Swedish National Institute of Public Health (17). Corresponding figures are just over 0.3% of total DALYs lost in the CCEE and the westernmost NIS but 10% for the area including the central Asian republics (18).

Havelaar et al. (19) attempted to estimate the number of DALYs lost an-nually in the Netherlands as a result of Campylobacter-related ill health. The Netherlands had a notified incidence of 18–24 cases per 100 000 population from 1994 to 1998. Making adjustments for unreported cases and allowing that such cases would be likely to be less serious, the authors estimated that Campylobacter causes the loss of about 1400 DALYs annually. Although this figure is small compared with the burden of major chronic diseases in the Netherlands, such as diabetes (87 500 DALYs) or stroke (169 600 DALYs) (20), it nevertheless points to a significant burden of potentially avoidable dis-ease related to foodborne infections, with social and economic consequences for communities and their health care systems.

Economic burden

Studies have attempted to put a monetary value on the burden of foodborne disease. The numerous contributory factors – such as the severity of the ill-ness, lost productivity, the costs of health care and any laboratory investiga-tion – introduce considerable variability into these estimates, but all point to a substantial overall total. In the United Kingdom, a single case of laboratory-confirmed salmonellosis was estimated to cost nearly £800 in 1990, including the need to hospitalize some patients, their loss of earnings, the disruption to

Table 2.3. Comparison of food safety hazards in Denmark

a 1 = increased effort required; 2 = increased effort required in the longer term;

3 = reduced effort required in the longer term.

Source: adapted from Danish Veterinary and Food Administration (16).

Foodborne hazard Annual disease burden Food control effort rating^a Cases per million

population

Cancer deaths

Salmonella 10 000–20 000 2

Campylobacter 6 000–12 000 1

L. monocytogenes 8 2

E. coli O157:H7 2–4 1

Yersinia 1 000–2 000 3

Hepatitis A 2–40 3

Prions 0 2

Parasites >20 3

Aflatoxins < 0.1 3

Dioxins, PCBs Unknown 2

Polycyclic aromatic hydrocarbons

20–60

2

Nitrosamines 0.04–0.4 2

the victim’s family and lost economic output (21) (Table 2.4). The costs asso-ciated with vCJD are considerably higher. In the United Kingdom, care and treatment of people with vCJD is estimated to cost the health services about

£45 000 per case (22), and a further £220 000 may be paid to each family as part of the Government’s no-fault compensation scheme (23).

Table 2.4. Estimated average cost of a laboratory-investigated case of salmonellosis, 1990

Source: adapted from Sockett & Roberts (21).

The infectious intestinal diseases study in England estimated that there were 9.4 million cases annually with a total estimated cost of £3–4 billion per year in 1994–1995 costs (10). It estimated that less than half the cases were foodborne, but the cost of each foodborne case (including those not reported) was assessed at £79.

The costs of preventing a disease from entering the human population once it has been able to contaminate the food supply may also be high. The cost of eliminating BSE in cattle in Europe is estimated to be €13 billion.

Political consequences

Notable recent food safety issues have raised widespread concern and distrust of official scientific opinion in consumers. This, in turn, has led to increased political and government involvement in food regulation activities. These epi-sodes have also highlighted the risk that food safety can be compromised if a single government department is responsible for both regulating the food and farming industries and promoting their interests.

Dioxin-contaminated animal feed from a single source in Belgium was dis-tributed to more than 1500 farms in Europe over 2 weeks in 1999 (24). The delay in informing EU officials led to criticism from the European Commis-sion (EC), the institution of legal proceedings against the Government of Bel-gium and ministers’ resignations (25,26).

BSE, addressed in detail below, has probably led to more political and structural change in western Europe than any other food or agricultural issue.

Factor Cost per case (£)

Local authority investigations 58 Laboratory investigations 48

General practice costs 29

Hospital costs 167

Prescribed medicines 6

Loss of production 413

Other costs 67

Total 788

In Germany, the emergence of BSE in early 2001 led to the resignation of both the agriculture and health ministers and the restructuring of the agricul-ture ministry to become more consumer-oriented (27). In the United King-dom, responsibilities for food control were transferred from the Ministry of Agriculture, Fisheries and Food and to a new, separate food authority: the Food Standards Agency. Elsewhere in Europe, similar national agencies have been created to ensure adequate regulation of food safety and restore public confidence (12), and a European Food Safety Authority has been established.

BSE, along with other food concerns, also contributed to the reform of the EC structure, with the establishment of a single directorate responsible for con-sumer, food safety and health issues. The Scientific Steering Committee – the EC’s main scientific advisory body, set up to advise on all aspects of consumer health – published some 106 opinions and related documents from January 1998 to October 2001, 96 of which are related to BSE (http://europa.eu.int/

comm/food/fs/sc/ssc/outcome_en.html, accessed 6 October 2002).

Efforts to increase public confidence in the wake of BSE included moves to increase transparency in policy-making and to improve consumer access to the scientific risk assessment process at the national, EU and Codex Alimenta-rius Commission levels. A more precautionary approach to food safety issues is also apparent. Response to the possible link between Mycobacterium avium subsp. paratuberculosis in milk and Crohn’s disease in human beings provides an example: an EU expert committee concluded that “There are sufficient grounds for concern to warrant increased and urgent research activity to re-solve the issue” (28). While uncertainty remains, it has nevertheless been pro-posed to improve hygiene and extend pasteurization times to reduce the inci-dence of M. avium subsp. paratuberculosis in milk (10).