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• W1992222710 abstract "The World Health Organization estimates that in 2005, 1.5 million people died, worldwide, from diarrheal diseases. A separate study estimated that 70% of diarrheal diseases are foodborne. The widely cited US estimate is that there are 76 million foodborne illnesses annually, resulting in 325,000 hospitalizations and 5200 deaths. However, there are epidemiologic and methodologic challenges to accurately estimate the economic burden of foodborne disease on society, either in terms of monetary costs or non-monetary units of measurement. Studies on the economic burden of foodborne disease vary considerably: some analyze the effects of a single pathogen or a single outbreak, whereas others attempt to estimate all foodborne disease in a country. Differences in surveillance systems, methodology, and other factors preclude meaningful comparisons across existing studies. However, if it were possible to completely estimate the societal costs for all acute foodborne diseases and their chronic sequelae worldwide, on the basis of currently available data, worldwide costs from these illnesses would be substantial. Moreover, foodborne infections are largely manifested as intestinal illnesses and are largely preventable. Total costs of foodborne disease would be much smaller in the United States and the world if economic incentives for industry to produce safer food were improved. However, costs of implementing new food safety prevention and control rules must be weighed against the estimated benefits of reducing foodborne disease to determine net benefits so that governments have information to efficiently allocate funds among competing programs. The World Health Organization estimates that in 2005, 1.5 million people died, worldwide, from diarrheal diseases. A separate study estimated that 70% of diarrheal diseases are foodborne. The widely cited US estimate is that there are 76 million foodborne illnesses annually, resulting in 325,000 hospitalizations and 5200 deaths. However, there are epidemiologic and methodologic challenges to accurately estimate the economic burden of foodborne disease on society, either in terms of monetary costs or non-monetary units of measurement. Studies on the economic burden of foodborne disease vary considerably: some analyze the effects of a single pathogen or a single outbreak, whereas others attempt to estimate all foodborne disease in a country. Differences in surveillance systems, methodology, and other factors preclude meaningful comparisons across existing studies. However, if it were possible to completely estimate the societal costs for all acute foodborne diseases and their chronic sequelae worldwide, on the basis of currently available data, worldwide costs from these illnesses would be substantial. Moreover, foodborne infections are largely manifested as intestinal illnesses and are largely preventable. Total costs of foodborne disease would be much smaller in the United States and the world if economic incentives for industry to produce safer food were improved. However, costs of implementing new food safety prevention and control rules must be weighed against the estimated benefits of reducing foodborne disease to determine net benefits so that governments have information to efficiently allocate funds among competing programs. Tanya RobertsView Large Image Figure ViewerDownload Hi-res image Download (PPT)The World Health Organization (WHO) estimates that 1.5 million people died, worldwide, from diarrheal diseases in 2005.1World Health Organization (WHO)Food safety and foodborne illness. WHO, Geneva, Switzerland2008www.who.int/mediacentre/factsheets/fs237/en/Google Scholar A separate study estimated that 70% of diarrheal diseases are foodborne.2Käfferstein F.K. Food safety as a public health issue for developing countries.in: Unnevehr L.J. Food safety in food security and food trade Brief 2 of 17. International Food Policy Research Institute, Washington DC2003Google Scholar Data on the extent of foodborne illnesses and associated deaths are incomplete and understate the problem in both developed and developing countries.3Organization for Economic Co-operation and Development (OECD), World Health Organization (WHO)Foodborne disease in OECD countries: present states and economic costs. OECD, Paris, France2003Google Scholar The widely cited US estimate by Mead et al4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar at the Centers for Disease Control and Prevention (CDC) is that 76 million foodborne illnesses occur annually in the United States, resulting in 325,000 hospitalizations and 5200 deaths. Every illness has an economic cost. For the practitioner, such costs have bearings if they influence decisions to diagnose or to treat, either consciously or unconsciously. Global macroeconomic consequences of such illnesses do not, however, influence daily practice. Nonetheless, infections of the gastrointestinal tract, and, most particularly, those that are foodborne and theoretically preventable exact considerable expense worldwide. Because of the role of gastroenterologists in the management of affected patients, and as advocates for patients and populations who wish not to acquire these infections, we take the opportunity of this review to present large-scale implications of foodborne illnesses. On a per patient scale, foodborne disease costs can be considerable, particularly for the more severe cases. For example, Table 1 presents total cost estimates for STEC O157 (ie, Shiga toxin-producing Escherichia coli O157) and shows how average estimated costs per case vary by severity level. The estimated average cost for STEC O157 is $6256 per case.5Economic Research Service, US Department of AgricultureFoodborne illness cost calculator: STEC O157. Economic Research Service, US Dept of Agriculture, Washington, DC2008www.ers.usda.gov/Data/FoodborneIllness/ecoli_Intro.aspGoogle ScholarTable 1Estimated STEC O157 Costs, From All Sources, 2007 DollarsSeverity levelTotal cases (n)Total costs ($)Average cost per case ($)Not hospitalized Did not visit physician; survived57,6561,645,02429 Visited physician, survived13,6567,045,354516Hospitalized Did not have HUS; survived179712,438,4596922 Had HUS but not ESRD; survived30011,608,42038,695 Had HUS and ESRD; survived1058,687,6075,868,761 Did not have HUS; died23103,657,2474,506,837 Had HUS, died38264,625,3826,963,826Total73,480459,707,4936256NOTE: Although these figures are for STEC O157 illnesses from all sources, average foodborne illness costs are usually considered to be the same as costs for those illnesses from non-foodborne sources.ESRD, end-stage renal disease; HUS, hemolytic uremic syndrome, which is characterized by red blood cell destruction, kidney failure, and neurologic complications, such as seizures and strokes;Source: Economic Research Service.5Economic Research Service, US Department of AgricultureFoodborne illness cost calculator: STEC O157. Economic Research Service, US Dept of Agriculture, Washington, DC2008www.ers.usda.gov/Data/FoodborneIllness/ecoli_Intro.aspGoogle Scholar Open table in a new tab NOTE: Although these figures are for STEC O157 illnesses from all sources, average foodborne illness costs are usually considered to be the same as costs for those illnesses from non-foodborne sources. ESRD, end-stage renal disease; HUS, hemolytic uremic syndrome, which is characterized by red blood cell destruction, kidney failure, and neurologic complications, such as seizures and strokes; Source: Economic Research Service.5Economic Research Service, US Department of AgricultureFoodborne illness cost calculator: STEC O157. Economic Research Service, US Dept of Agriculture, Washington, DC2008www.ers.usda.gov/Data/FoodborneIllness/ecoli_Intro.aspGoogle Scholar Much of the US data on foodborne disease are from the Foodborne Diseases Active Surveillance Network (FoodNet), which is a collaborative effort between the CDC, the US Department of Agriculture (USDA), the Food and Drug Administration, and 10 participating state health departments.6Jones T.F. Scallan E. Angulo F.J. FoodNet: overview of a decade of achievement.Foodborne Pathog Dis. 2007; 4: 60-66Crossref PubMed Scopus (45) Google Scholar, 7Scallan E. Activities, achievements, and lessons learned during the first 10 years of foodborne diseases active surveillance network: 1996–2005.Clin Infect Dis. 2007; 44: 718-725Crossref PubMed Scopus (85) Google Scholar FoodNet performs active, population-based laboratory surveillance in selected sites around the United States and covers a select group of pathogens (ie, Campylobacter, Cryptosporidium, Cyclospora, Listeria monocytogenes, STEC O157, STEC non-O157, Salmonella, Shigella, Vibrio, and Yersinia enterocolitica).6Jones T.F. Scallan E. Angulo F.J. FoodNet: overview of a decade of achievement.Foodborne Pathog Dis. 2007; 4: 60-66Crossref PubMed Scopus (45) Google Scholar, 7Scallan E. Activities, achievements, and lessons learned during the first 10 years of foodborne diseases active surveillance network: 1996–2005.Clin Infect Dis. 2007; 44: 718-725Crossref PubMed Scopus (85) Google Scholar FoodNet augments surveillance information with surveys of clinical laboratories and the general public to better understand the burden of disease. Population demographics from FoodNet find that the young are more likely to be infected with a foodborne pathogen, yet those older than 70 years are more likely to die of the illness (Table 2).Table 2Illnesses, Hospitalizations, and Deaths in FoodNet as a Result of Pathogens Commonly Transmitted Through Food by Age, 2001–2005Case severityTotal cases (n)Age0–14 y15–69 y≥70 yn%n%n%IllnessesaPersons who have visited a doctor because of an illness, a stool sample has been taken, and the infection is confirmed and is in the FoodNet database.63,42225,8214135,2635523384Required hospitalization15,420482831844455214814Death from foodborne illness36836101584317447NOTE: The illness severity categories are mutually exclusive and include the pathogens covered by FoodNet.Source: Age breakdown of FoodNet data (Ida Rosenblum, FoodNet CDC, e-mail communication April 2007).a Persons who have visited a doctor because of an illness, a stool sample has been taken, and the infection is confirmed and is in the FoodNet database. Open table in a new tab NOTE: The illness severity categories are mutually exclusive and include the pathogens covered by FoodNet. Source: Age breakdown of FoodNet data (Ida Rosenblum, FoodNet CDC, e-mail communication April 2007). Collectively, foodborne diseases pose enormous financial costs on communities, individual nations, and the world. For example, US foodborne costs for 6 bacterial pathogens and 1 parasite were estimated at $6.5 billion to $34.9 billion annually,8Buzby J.C. Roberts T. Economic costs and trade impacts of microbial foodborne illness.World Health Stat Q. 1997; 50: 5-66PubMed Google Scholar which is an underestimate of total foodborne disease costs because there may be >200 microbiologic agents that cause foodborne disease.4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar Other countries have also estimated annual costs for foodborne diseases, and global estimates of the burden of foodborne disease are currently being developed. Snowdon et al9Snowdon J.A. Buzby J.C. Roberts T. Epidemiology, cost, and risk of foodborne disease.in: Cliver D. Riemann H. Foodborne diseases. 2nd ed. Elsevier Press, Amsterdam, The Netherlands2002: 31-51Google Scholar speculated that the economic consequences of foodborne disease are substantial in both industrialized and developing nations, although the consequences may be greater in developing countries because of high incidence of infant mortality, malnutrition, and chronic diarrhea. Foodborne illness generates costs that are borne by households whose members become ill, the food industry, and the regulatory and public health sectors (Figure 1). The array of societal costs of foodborne illnesses in these 3 main groups is shown in Table 3. Analyses that estimate the costs of foodborne disease often include only the medical costs of individuals or household, costs of lost productivity, and premature death and exclude others costs (eg, pain and suffering, institutional care) because of lack of adequate data.Table 3Societal Costs of Foodborne IllnessCosts to individuals or householdsaWillingness-to-pay estimates for reducing risks of foodborne disease is a comprehensive estimate of all these categories (assuming that the individuals have included employer-funded sick leave and medical programs in their estimates). The estimate is comprehensive and covers reduced risks for everyone: those who will become ill as well as those who will not. Human illness costs Medical costs Physician visits Laboratory costs Hospitalization or nursing home Drugs and other medications Ambulance or other travel costs Income or productivity loss for Ill person or person dying Caregiver for ill person Other illness costs Travel costs to visit ill person Home modifications Vocational/physical rehabilitation Child care costs Special educational programs Institutional care Lost leisure time Psychological costs Pain and other psychological suffering Risk aversion Averting behavior costs Extra cleaning or cooking time costs Extra cost of refrigerator, freezer, etc Flavor changes from traditional recipes (especially meat, milk, egg dishes) Increased food cost when more expensive but safer foods are purchased Altruism (willingness to pay for others to avoid illness)Industry costsbSome industry costs may fall with better pathogen control, such as reduced product spoilage, possible increases in product shelf-life, and extended shelf-life, permitting shipment to more distant markets or lowering shipment costs to nearby markets. Costs of animal production Morbidity and mortality of animals on farms Reduced growth rate or feed efficiency and increased time to market Costs of disposal of contaminated animals on farm and at slaughterhouse Increased trimming or reworking at slaughterhouse and processing plant Illness among workers because of handling contaminated animals or products Increased meat product spoilage because of pathogen contamination Control costs for pathogens at all links in the food chain New farm practices (age-segregated housing, sterilized feed, etc) Altered animal transport and marketing patterns (animal identification, feeding or watering) New slaughterhouse procedures (hide wash, knife sterilization, carcass sterilizing) New processing procedures (pathogen tests, contract purchasing requirements) Altered product transport (increased use of time or temperature indicators) New wholesale or retail practices (pathogen tests, employee training, procedures) Risk assessment modeling by industry for all links in the food chain Price incentives for pathogen-reduced product at each link in the food chain Outbreak costs Herd slaughter or product recall Plant closings and cleanup Regulatory fines Product liability suits from consumers and other firms Reduced product demand because of outbreak: Generic animal product, all firms affected Reduction for specific firm at wholesale or retail level Increased advertising or consumer assurances after outbreakRegulatory and public health sector costs for foodborne pathogens Disease surveillance costs to Monitor incidence or severity of human disease by foodborne pathogens Monitor pathogen incidence in the food chain Develop integrated database from farm to table for foodborne pathogens Research to Identify new foodborne pathogens for acute and chronic human illnesses Establish high-risk products and production and consumption practices Identify which consumers are at high risk for which pathogens Develop cheaper and faster pathogen tests Risk assessment modeling for all links in the food chain Outbreak costs Costs of investigating outbreak Testing to contain an outbreak (eg, serum testing and administering immunoglobulin in persons exposed to hepatitis A) Costs of cleanup Legal suits to enforce regulations that may have been violatedcIn adding up costs, care must be taken to assure that product liability costs to firms are not already counted in the estimated pain and suffering cost to individuals. However, the legal and court expenses incurred by all parties are societal costs. Other considerations: Distributional effects in different regions, industries, etc Equity considerations, such as special concern for childrena Willingness-to-pay estimates for reducing risks of foodborne disease is a comprehensive estimate of all these categories (assuming that the individuals have included employer-funded sick leave and medical programs in their estimates). The estimate is comprehensive and covers reduced risks for everyone: those who will become ill as well as those who will not.b Some industry costs may fall with better pathogen control, such as reduced product spoilage, possible increases in product shelf-life, and extended shelf-life, permitting shipment to more distant markets or lowering shipment costs to nearby markets.c In adding up costs, care must be taken to assure that product liability costs to firms are not already counted in the estimated pain and suffering cost to individuals. However, the legal and court expenses incurred by all parties are societal costs. Open table in a new tab The WHO defines the burden of disease as “the incidence and prevalence of morbidity, disability, and mortality associated with acute and chronic manifestations of diseases.”10World Health Organization (WHO)WHO consultation to develop a strategy to estimate the global burden of foodborne diseases: taking stock and charting the way forward. WHO, Geneva, Switzerland2006Google Scholar Here, we take this one step further and are interested in the economic burden of foodborne disease, meaning that we are interested in translating the different outcomes or effect of foodborne disease into a common unit of measurement, such as monetary costs or a non-monetary unit of measurement. Why is it important to estimate the economic burden of a foodborne disease? These estimates can be used in the following multiple ways:•Evaluate the economic burden of all or a group of foodborne diseases.•Provide justification for the need to strengthen support for increased surveillance and prevention of foodborne diseases by national or by international organizations, such as the WHO.•Provide input to a benefit–cost analysis of a proposed food safety rule or a cost-effectiveness analysis (CEA), to obtain information needed in policy making. From an economic perspective, the societal benefits of a food safety regulation are the costs of foodborne disease that would be prevented if the regulation was put in place, such as savings in disease prevention and mitigation expenditures, increases in worker productivity, and reductions in medical costs, pain and suffering.•Aid comparisons and other analyses, such as for:○Comparing the estimated costs for different foodborne diseases. Although this information can help determine the order for targeting pathogen prevention and control efforts toward the most costly diseases, information on prevention and control costs is also needed to determine whether and where there are positive net benefits from implementing food safety programs.○Comparing benefits and costs of alternative pathogen prevention and control programs and strategies to find cost-effective interventions so that resources are appropriately allocated.○Monitoring and evaluating food safety measures over time. They can also give countries a sense of what to expect in terms of the disease burden in the future.10World Health Organization (WHO)WHO consultation to develop a strategy to estimate the global burden of foodborne diseases: taking stock and charting the way forward. WHO, Geneva, Switzerland2006Google Scholar There are 5 main epidemiological challenges when estimating the economic burden of foodborne disease. Estimating the annual number of illnesses each year caused by a particular pathogen is difficult. This is a challenge because some unknown portion of ill people never see a doctor, many visits do not result in a diagnosable pathogen because the specimen is not obtained, or the laboratory testing does not seek or identify the causative agent.11US Centers for Disease Control and Prevention (CDC)Foodborne illness. CDC, Atlanta, GA2008www.cdc.gov/ncidod/dbmd/diseaseinfo/foodborneinfections_g.htmGoogle ScholarFigure 2 illustrates the steps that must occur for a person who becomes ill to be identified as a laboratory-confirmed case that is reported to public health surveillance. In 2007, FoodNet identified a total of 17,883 laboratory-confirmed cases of foodborne infection.12US Centers for Disease Control and Prevention (CDC)Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food—10 States, 2007.MMWR Morb Mortal Wkly Rep. 2008; 57 (14): 366-370PubMed Google Scholar This estimate represents those laboratory-confirmed cases in which an illness is linked to a specific pathogen and reported to the CDC. As previously mentioned, FoodNet uses a variety of tools to make its estimates. Information from active surveillance and the FoodNet surveys of clinical laboratories and the general population are used to estimate the total number of foodborne illnesses in the population. With this information, Mead et al4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar estimated that 76 million foodborne disease cases occur annually in the United States. FoodNet now covers 15% of the US population6Jones T.F. Scallan E. Angulo F.J. FoodNet: overview of a decade of achievement.Foodborne Pathog Dis. 2007; 4: 60-66Crossref PubMed Scopus (45) Google Scholar, 7Scallan E. Activities, achievements, and lessons learned during the first 10 years of foodborne diseases active surveillance network: 1996–2005.Clin Infect Dis. 2007; 44: 718-725Crossref PubMed Scopus (85) Google Scholar; FoodNet also conducts a variety of epidemiologic studies, including case–control studies for sporadic cases from specific pathogens.6Jones T.F. Scallan E. Angulo F.J. FoodNet: overview of a decade of achievement.Foodborne Pathog Dis. 2007; 4: 60-66Crossref PubMed Scopus (45) Google Scholar One particular difficulty in estimating the total cost of foodborne disease is that the causes of most cases of gastrointestinal distress are never identified. Because of the mild nature of most of these illnesses, the causes are usually not investigated, and, as a result, they are frequently excluded from cost studies. Mead et al4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar found that unknown agents accounted for approximately 81% of foodborne illnesses in the United States and 64% of deaths. Hence, the actual spectrum of all causes of foodborne disease is not definitive, and, as a result, the overall economic analysis will be similarly restricted. Total estimated costs of foodborne disease will be underestimated if the economic studies do not include the unknown pathogens from Mead et al4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar or other sources, particularly the more severe cases. Frenzen13Frenzen P.D. Mortality due to gastroenteritis of unknown etiology in the United States.J Infect Dis. 2003; 187: 441-452Crossref PubMed Scopus (30) Google Scholar estimated that gastroenteritis of unknown cause was responsible for 4400 deaths in the United States each year but found no direct evidence that unknown foodborne agents were a main cause of these deaths.14Frenzen P.D. Deaths due to unknown foodborne agents.Emerging Infect Dis. 2004; 10: 1536-1543Crossref PubMed Scopus (24) Google Scholar Information about the share of illnesses that are a result of specific foods is limited. Economic analyses need this information to estimate the number of foodborne disease cases that might be prevented by a proposed regulation. For example, the official regulatory impact analysis of the Pathogen Reduction/Hazard Analysis and Critical Control Program (PR/HACCP) for federally inspected meat and poultry slaughter and processing plants required assumptions about what portion of all cases of salmonellosis, campylobacteriosis, and other select foodborne disease cases were due to meat and poultry.15Pathogen reduction; hazard analysis and critical control point (HACCP) systems, final rule. Fed Reg July 25, 1996;61(144):38805–3989.Google Scholar The proportion attributed to foodborne transmission varies greatly, from 1% for rotaviruses to 100% for Bacillus cereus.4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar FoodNet conducted case–control studies to determine the foods that cause sporadic illnesses. The best information linking pathogens to specific foods are from foodborne disease outbreak data. However, Mead et al4Mead P.S. Slutsker L. Dietz V. et al.Food-related illness and death in the United States.Emerging Infect Dis. 1999; 5: 607-625Crossref PubMed Scopus (5671) Google Scholar estimated that only 0.008% of all foodborne illness cases in the United States are identified in an outbreak, and more recent research suggests that in sporadic cases vehicles can differ considerably from those implicated in outbreaks.16Denno D.M. Keene W.E. Hutter C.M. et al.Tri-county comprehensive assessment of risk factors for sporadic bacterial enteric infections in children.J Infect Dis. 2009; 199: 467-476Crossref PubMed Scopus (58) Google Scholar For estimation purposes, the share of a particular foodborne disease to a particular food vehicle is often obtained from expert opinion or targeted studies and literature on that pathogen. A variety of analytical approaches and data sources are used to attribute illness to particular foods, such as case–control studies and microbial subtyping.17Batz M.B. Doyle M.P. Morris J.G. et al.Attributing illness to food.Emerging Infect Dis. 2005; 11: 993-999Crossref PubMed Scopus (146) Google Scholar For most pathogens, data are limited on the distribution of outcome severity. A thorough economic evaluation requires information on the severity of illness, the duration, and outcomes, ranging from regaining full health to death. Although FoodNet collects information on 3 illness severities (Table 2), it covers only a handful of pathogens. A fourth challenge is that most foodborne pathogens cause one or more chronic complications that can have lifetime health consequences or cause premature death. These chronic sequelae include paralysis, kidney failure, irritable bowel syndrome, Guillain–Barré syndrome (GBS), and arthritis. Reactive arthritis is a good example of a chronic sequela because it is an autoimmune disease caused in response to infections, such as by many foodborne bacterial pathogens. The disease outcome tree (Figure 3) shows the range of lifetime outcomes, starting with reactive arthritis, in approximately 8% of cases of foodborne disease (ie, this is the best estimate, with the ranges given).18Raybourne R.B. Williams K.M. Roberts T. Food poisoning: economic implications.in: Encyclopedia of food sciences and nutrition. Vol 1. Elsevier Science Ltd, London, United Kingdom2003: 2672-2682Google Scholar It is important to include chronic sequelae in cost studies because they can result in high average and total costs. For example, Maxion–Bergemann et al19Maxion-Bergemann S. Thielecke F. Abel F. et al.Costs of irritable bowel syndrome in the UK and US.Pharmacoeconomics. 2006; 24: 21-37Crossref PubMed Scopus (21) Google Scholar estimated per patient costs for irritable bowel syndrome and concluded that it is an expensive and common disorder. Estimated annual total US costs of Campylobacter-associated GBS linked to food were $136.0 million to $1.3 billion in 1995.20Buzby J.C. Roberts T. Mishu Allos B. Estimated annual costs of Campylobacter-associated Guillain-Barré Syndrome. US Dept of Agriculture, Economic Research Service, Washington, DC1997www.ers.usda.gov/publications/Aer756/Google Scholar Most foodborne illnesses do not result in chronic complications or loss of life. However, acute and chronic complications from a given exposure to a foodborne pathogen can vary and can be difficult to measure and compare across countries for the following reasons:•Immune system variability between individuals. Some individuals have a better immune response to pathogens than others.•Pathogen strain variability. Some strains of foodborne disease exhibit greater ease of interpersonal transmission, such as STEC O157.21Werber D. Mason B.W. Evans M.R. et al.Preventing household transmission of Shiga toxin-producing Escherichia coli O157 infection: promptly separating siblings might be the key.Clin Infect Di" @default.
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• W1992222710 title "The Economics of Enteric Infections: Human Foodborne Disease Costs" @default.
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