Salmonellosis Control: Estimated Economic Costs1

Salmonellosis Control: Estimated Economic Costs 1 TANYA ROBERTS USDA, Economic Research Service, 1301 New York Avenue, N.W., Room 1108, Washington, DC 20005-4788 (Received for publication December 29, 1987)

1988 Poultry Science 67:936-943 INTRODUCTION

Foodborne disease, such as the intestinal disease salmonellosis, results when two events occur: 1) food is contaminated by organisms pathogenic to humans, and 2) these pathogens are not killed by cooking, salting, or some other means [their numbers may actually be increased by insufficient cooking or insufficient refrigeration (Bryan, 1980)]. Foods containing animal or seafood proteins are more likely to contain human pathogens than fruits and vegetables, consequently the meat industries must be alert to the potential contamination of their products. From an economist's perspective the existence of a poor quality product, such as contaminated food, does not by itself indicate a problem that cannot be corrected by the market place. With virtually any product purchased, there are possibilities of bad product performance-extension cords that do not transmit electricity, strawberries that mold the day after purchase, and new cars whose radios do not work. If the consumer doesn't like the performance of the prod-

'The views are not official policy of the USDA.

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uct, he can either ask for his money back or ask for a replacement-actions firmly supported by the legal system. Or the consumer can refuse to buy the product in the future (give up strawberries), change his shopping habits (buy strawberries only when he plans to use them that day), change stores (maybe another store buys fresher berries and handles them to extend shelf-life), or switch to a higher quality product or another product (frozen strawberries) that will perform to his satisfaction. All these actions are market solutions to the problem of inferior products and result in sales signals sent back to producers. The problem with contaminated food lies in the absence of information about product performance. For someone ill with salmonellosis, it is difficult to tell that what one ate made one sick. Most people who fall ill in salmonellosis outbreaks believe they have the stomach flu, not salmonellosis (R. V. Tauxe, 1987, personal communication). If one does make the connection to a foodborne illness, one cannot always identify which food made one sick. For example, the average time until onset of disease for campylobacteriosis (another intestinal disease associated with poultry) is 3 to 4 days, and it may be up to a week before the onset of illness. Even if one can identify what food is likely to

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ABSTRACT Salmonellosis, a common human intestinal disorder primarily caused by Salmonella-contaminated meats and poultry, was estimated to cost Americans around one billion dollars in 1987. Only medical costs and productivity losses were included in the estimate of costs of the two million cases estimated to occur annually. If pain and suffering, lost leisure time, and chronic disease costs could be easily quantified, the estimate would increase significandy. Other procedures for calculating the value of life could change the estimates of economic benefits of reducing human salmonellosis. Incorporating losses to farmers, whose animals have reduced feed efficiency, reduced weight gain, or deaths because of chronic salmonellosis, would increase the size of estimates. Costs of food safety regulatory programs and costs to the industry for product recalls and plant closures due to foodborne salmonellosis outbreaks, if included, would also increase the size of estimates. The National Academy of Sciences has endorsed risk assessment as a necessary method for evaluating and improving food safety regulatory programs, especially as applied to Salmonella contamination of poultry. This report reviews and updates research on cost estimates of salmonellosis. Understanding the costs of salmonellosis is an important part of risk assessment, as a key objective of regulatory programs is reducing human salmonellosis. (Key words: Salmonella, salmonellosis, foodborne disease costs, economic costs, risk assessment)

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METHODS

Risk assessment, the backbone of the hazard analysis at critical control points system recommended by the National Research Council of the National Academy of Sciences (1983, 1985,

1987), has not been systematically applied to salmonellosis caused by food. Risk assessment examines the potential entry points of Salmonella into food from farm to table, examines potential control procedures, and estimates the hazards to humans in terms of exposure, illness, and resulting costs. Economists view foodborne illness as arising out of a market activity such as purchasing meat at a supermarket or a restaurant and consuming it (Figure 1). This exposes the individual to a risk or hazard, namely the possibility of acquiring a foodborne illness. Only some of the exposed persons become ill. Costs associated with the illness include direct costs imposed on the parties in the market transaction-the person becoming ill from buying and consuming the product and the firm selling the product (Figure 1). The monetizable direct costs (those easily measured in dollars) include lost wages and medical costs for the risk person and lost sales, product recall, and costs associated with legal liability suits for the restaurant or supermarket. In addition, there are the nomonetizable direct costs such as the pain and inconvenience of the ill person who purchased the food. Other costs are called indirect costs because the affected parties are outside of the market transaction; they did not buy and consume the food and did not become ill. However, other family members and friends may still incur costs. An example of a monetizable, indirect cost is the expense of travel to visit a hospitalized family member. Again the most obvious nonmonetizable cost is the stress and disruption of having an ill family member. Costs in this study are limited to evaluating two components of human illness costs: medical costs and lost productivity (Figure 1). Omitted from the analysis are estimates of the costs of pain and suffering, reduction of leisure time choices, and other costs to individuals. Industry costs of reduced animal performance or product recall and plant cleanup during a foodborne disease outbreak are also omitted, as well as the cost of the public health surveillance system. Methods of estimating costs are based on procedures used to derive cost estimates of human salmonellosis cases by the Centers for Disease Control (CDC) in Atlanta. The three CDC estimates are: 1) Outbreak data for all foodborne diseases, which are primarily reported by state health departments: salmonellosis typically has around 50 outbreaks and around 2,000 as-

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have caused the illness, usually the food has been eaten or thrown out by the time of onset of illness and is not available for testing for contaminants. Epidemiological surveys may be able to track down the disease source, but only at great expense. Because the connection between food and disease is difficult to make, corrective market signals are not sent back to producers. In fact, producers get signals telling them that they do not need to correct the problem: after a foodborne disease episode, people do not stop purchasing the product that made them ill (because they do not know what it is). Quantities and prices of the food causing illness do not fall. Grocery stores and restaurants seldom receive complaints. Even less frequently does a beef, chicken, or pork slaughter plant hear about diseases their products may have caused; farmers raising these animals hear even less frequently. This lack of communication does not mean a lack of foodborne disease. It means a lack of an understanding of the seriousness of foodborne disease. It means a lack of incentives to change production and handling practices to minimize contamination of food with human pathogens such as Salmonella, Campylobacter, Trichinella, Toxoplasma, Taenia, Staphylococcus, Bacillus, and Clostridium (National Research Council, 1985). Food safety is a classic example of a market failure due to imperfect information: consumers become ill but producers do not see a fall in purchases. Consequently, producers do not change their practices and foodborne disease is not reduced. This lack of information has another dimension. Consumers cannot easily take preventive actions and avoid contaminated products. They cannot look at a chicken leg in a grocery store, a chicken salad sandwich in a delicatessen, or chicken kiev in a restaurant and choose only those products that will not make them ill. Because of the information problem, as a society we have delegated food safety regulation to federal and state governments. Even the regulators have trouble detecting microscopic pathogens as the National Academy of Sciences pointed out (National Research Council, 1987).

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sociated cases annually. 2) Salmonellosis surveillance activity data, which are reported by private and public health workers: average about 40,000 cases annually. 3) Extrapolations from the outbreak and surveillance data by CDC to estimate the "true" incidence of salmonellosis

which ranges from 400,000 to 4,000,000 human cases annually (Cohen and Tauxe, 1986). Both outbreak data and surveillance data are clear underestimates. Infection may not be suspected, cultured, diagnosed, or reported for a variety of reasons. Community surveys during outbreaks

Household production

Food industry production

Public health regulations

I I Presence of a hazard in food

Exposure to a hazard via consumption of food

T Incidence of damage

I Food industry Product recall Plant closings and cleanup Product liability cost1 Reduced product demand

Households Medical cost Income or productivity loss Pain and suffering Leisure time cost Child care cost Risk aversion cost Travel cost Averting behavior cost

Public health sector Disease surveillance cost Cost of investigating outbreak Cost of cleanup

Cost of damage

Monetizable cost

Nonmonetizable cost

In adding up costs, care must be taken to assure that product liability cost to firms is not already counted in the estimated pain and suffering cost to individuals. FIGURE 1. Costs from exposure to foodborne disease.

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Food production, marketing & preparation

SYMPOSIUM: CONTROL OF SALMONELLA CONTAMINATION OF POULTRY

people were asked how much they would be willing to pay to have less risk in their jobs. From their replies a monetary value for risk reduction was calculated. Fisher et al. (1986, unpublished data) concluded that the results were relatively consistent with each other and indicate a value of a statistical life saved of $1.6 to $8.4 million. However, Gerking (1987, unpublished seminar) indicates that people give overestimates in such surveys compared to actual market purchases. Because of the lack of consensus, this method is not used here. The time-honored method of valuing the actuarial loss of someone's death is the human capital method pioneered by Dorothy Rice (Cooper and Rice, 1978). An individual is valued by the wages she would have received over the remainder of her lifetime. The courts have used this method extensively to make the family whole, i.e., to replace the lost earnings of a family member. Landefeld and Seskin (1982) have adjusted the human capital method to make it more consistent with individual preferences and what people are willing to pay to reduce risk. Income available to pay for risk reduction is expanded to include nonlabor income, such as earnings from real estate and stocks and bonds, as well as wages. The interest rate reflects the individual's (not society's) opportunity cost of investing in risk reducing activities, such as buying smoke alarms, and is estimated at 3%. A risk aversion factor is added, as studies have shown that households are willing to pay more than their actuarial loss for other household risks, for example fire insurance. The risk aversion factor used by Landefeld and Seskin (1982) increases the estimates by 60%. The adjusted human capital value of life formula is:

T

value of life = [2

Y t /(1 + r)l]a

where T = remaining lifetime, t = a particular year, Yt = after-tax income including labor and nonlabor income, r = household's opportunity cost of investing in risk-reducing activities, and a = risk aversion factor. Landfeld and Seskin's (1982) adjustments increase the value of avoiding death estimates roughly fourfold for salmonellosis deaths when compared with the unadjusted human capital method (Roberts, 1985).

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suggest that the proportions of actual infections reported are between 1 in 10 and 1 in 100. Thus CDC estimates that between 400,000 and 4,000,000 cases may occur annually (Cohen and Tauxe, 1986). The CDC's "best estimate" is 2 million salmonellosis cases annually (Bennett et al, 1987). Individuals vary greatly in their susceptibility to salmonellosis, depending partly on the virulence of the organism (there are over 1,500 Salmonella serotypes) and partly on the individual's immune system, along with other factors. As few as 10 Salmonella cells per gram or milliliter of food have caused human illness (Mulder, 1982). Typically, Salmonella-caused disease in humans is limited to salmonellosis, an acute gastroenteritis that appears 12 to 74 h after eating contaminated food. Salmonellosis may cause only mild abdominal discomfort, with minimal diarrhea lasting less than a day. More acute symptoms of disease include nausea, stomach ache, vomiting, diarrhea, cold chills, fever, and exhaustion. The symptoms of disease normally persist for 2 to 6 days, but in exceptional cases for several weeks. A small percentage of the people who contract salmonellosis die from it. Those most vulnerable are the sick, those taking antibiotics, infants, and the elderly. In rare cases Salmonella, like many other bacterial and parasitic infections, can cause chronic disease syndromes (Archer, 1984, 1985; Mossel, 1984; Cohen and Tauxe, 1986). Because of the variation in severity of salmonellosis cases, the estimated two million cases are divided into four categories: deaths, hospitalizations, persons seeing a doctor but not hospitalized, and those not seeking medical attention. Both a high and a low estimate were calculated for all four severity categories, based on Salmonella outbreak data and on Salmonella surveillance data. Cost estimates for the three illness severities (excluding deaths) were taken from Cohen et al. (1978) and updated using various price indices for medical care and wages published by the Bureau of Labor Statistics, US Department of Labor. These costs are not necessarily representative, but they are the only costs available in the literature. To be consistent with consumer behavior theory in economics, public programs for reducing risks of premature death should determine what people are willing to pay to reduce the risk of death. However, economists are still debating how to measure this cost. Fisher et al. (1986, unpublished data) reviewed six surveys where

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RESULTS

Deaths. Death certificate data reported to CDC showed only 79 deaths due to salmonellosis in 1979 (Public Health Service, US Dept. of Health and Human Services, 1984). Death certificate information is very inaccurate, for two reasons. Death certificates are filled out within hours of death and not updated with laboratory tests showing the causative organism. Even autopsy data are not subsequently entered on the death certificate. The CDC estimates of actual deaths from salmonellosis based on the Salmonellosis Surveillance data are made in the following way. A random sample of the 40,000 reported cases is examined to determine what percentage of the cases resulted in deaths. In 1979-80 1.3% died and in 1984-5 1.4% died, or roughly 500 people in each study (Cohen and Tauxe, 1986).

As the 40,000 reported cases are only a fraction of the estimated two million cases that occur, CDC doubles the deaths to an estimated 1,000 annually (R. V. Tauxe, 1987, personal communication) (Table 1). The second method for estimating salmonellosis deaths, using data from outbreaks of the foodborne disease, relies on outbreaks where virtually all cases have been identified. In such outbreaks, typically one in 1,000 cases results in death. Multiplying the estimated two million cases by this ratio gives an estimated 2,000 deaths annually (Bennett et al., 1987). Most reported deaths are of elderly people, with a few infants. Assuming the reported age distribution is representative of all estimated salmonellosis deaths, then it can be used with the Landefeld and Seskin (1982) numbers to estimate the benefits of reducing health risks from salmonellosis. Updated to April 1987 values using the Consumer Price Index (Bureau of Labor Statistics, 1987), the value for the stream of productivity lost for each premature salmonellosis death is $372,000. Multiplied times the 1,000 to 2,000 estimated deaths, the productivity loss due to death is estimated to range from $372 million to $744 million annually (Table 1). Hospitalized Cases. Cohen and Tauxe (1986) report that 18,000 of the 40,000 Salmonellosis Surveilance cases are hospitalized annually. Again because the 40,000 reported cases are only a fraction of the estimated actual 2,000,000 cases, Tauxe doubled the cases to estimate 36,000 hospitalizations for salmonellosis annually (R. V. Tauxe, 1987, personal communication). Outbreak data estimation comes from preliminary analysis of the 1985 Chicago salmonellosis outbreak. Hospitalized cases numbered 3,520. The hospitalization rate for the outbreak is 3,520 hospitalizations divided by the 200,000

TABLE 1. Salmonellosis medical costs and productivity losses in the US, 1987 Estimated cases Case severity category

Surveillance

Outbreak

Deaths Hospitalized cases Only saw doctor Mild cases (residual)

1,000 36,000 44,000 1,919,000

2,000 34,000 101,000 1,906,000

Total

2,000,000

2,000,000

Updated costs/case

Total costs Surveillance

Outbreak

372 157 30 424

744 148 69 421

($)

(llv/J

372,000 4,350 680 221

$983 million to $1.4 billion

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Because Landefeld and Seskin (1982) only include financial losses associated with death and omit psychic costs such as pain and suffering and the value of lost leisure time, the value of life lost is underestimated. As the methods used in this paper are based on their estimates, the value of life in this paper is also underestimated. Total costs depend upon disease severity. Salmonellosis cases are divided into four severity classes: deaths, hospitalized cases, cases in which a doctor is consulted either in her office or an emergency room (but not admitted to the hospital), and mild cases averaging two to three days of illness, which may include some time off work but no visit to the doctor. Two methods are used by the CDC to estimate the incidence of each of the four classes of cases. The first method is based on Salmonellosis Surveillance data, and the second is based on data from outbreaks of the disease (Cohen and Tauxe ,1986).

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TABLE 2. Salmonellosis costs in 1976 (Cohen et al., 1978) and costs updated to 1987 by three categories of salmonellosis severity Case severity category

1976 costs

Hospitalized cases Only doctor visit 111 but no doctor visit

1,750 222 125

1987 costs

Index used to update 1

4,350 680 221

Hospital rooms/CPI 2 Physicians services/CPI Average weekly earnings

($)

1 2

All updating indexes are published by the Bureau of Labor Statistics, US Department of Labor. CPI = Consumer price index.

by Caroline Ryan, CDC, to offset the higherthan-average rate of people seeking medical attention because of publicity and the possibility of class action suits against the dairy in this unusually well-publicized case). The rate of doctor visits then is 5.04% for the whole Chicago outbreak, or (16,000 x .63)/200,000. Multiplying 5.04% times the two million estimated US cases results in an estimated 101,000 doctor visits for salmonellosis annually. Costs for the doctor visits are again updated from Cohen et al. in 1978 (Table 2). In this instance the physician services component of the Consumer Price Index is used to update the numbers to October 1987 values. The average estimated cost for persons consulting a physician for salmonellosis is $680. Multiplied times the estimated cases, the estimated costs for these cases range from $30 to $69 million annually. Whereas physician expenses and laboratory tests were the key costs cited by Cohen et al. (1978; productivity loss is also included in the estimate. Mild Cases. One can assume that the remainder of the estimated two million cases are mild cases, or 1,191,000 cases, using extensions of Salmonellosis Surveillance data, and 1,906,000 cases, using extensions of the outbreak data. Cohen et al. (1978) roughly estimated costs for the mild cases, although their sample size was small. The costs were updated to April 1987 dollars using the change in average weekly earnings (Bureau of Labor Statistics, 1987), as the bulk of the cost is time away from work. Costs for the mild cases are roughly estimated at $221 apiece (Table 2). The total costs for mild cases are estimated to range between $421 and $424 million annually. In summary, the human illness costs of salmonellosis are substantial. Medical costs and lost productivity add up to a low estimate of $983 million annually using Salmonellosis Sur-

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total estimated cases for the Chicago outbreak, or 1.76% (C. Ryan, 1987, personal communication). Multiplying this percentage by the US annual estimate cases of salmonellosis results in an estimated 35,000 hospitalized cases (.0176 x 2,000,000 = 35,000, rounded to the nearest thousand). Costs are not yet available from the Chicago outbreak so Cohen et al. (1978) costs are updated to October 1987 values, using the hospital room component of the Consumer Price Index (Bureau of Labor Statistics, 1987) as shown in Table 2. The cost for hospitalized cases is estimated to be $4,350, multiplied times the number of hospitalizations results in an estimated cost of $148 to $157 million annually (Table 1). As Cohen et al. (1978) reported, most of the cost is for hospital expenses, followed by that for productivity loss during absence from work. Ill Enough to See a Doctor. Two studies of Salmonellosis Surveillance cases in 1979-80 and 1984-5 found that 22,000 of the 40,000 cases involved a visit to a doctor (Cohen and Tauxe, 1986). Extending these results to the estimated two million US salmonellosis cases annually, Tauxe (1987, personal communication) estimated that 44,000 people see a doctor because of salmonellosis. From the Chicago outbreak data the estimates are more complicated and still preliminary, with respect to numbers of those seeing doctors. A random sample of the 16,000 culture-confirmed cases was sent a questionnaire asking about the illness, 318 of the 600 answered the questionnaire. Of the respondents, 63% reported seeing a physician either in the emergency room or in a private office (C. Ryan, 1987, personal communication). Assume that 63% of the 16,000 confirmed cases saw a physician and that none of the remaining 200,000 cases saw a physician. (This conservative assumption was suggested

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veillance data and a high estimate of $ 1.4 billion annually using outbreak data for salmonellosis cases (Table 2). The difference between the low and high estimates reflects the two different methods of allocating cases into disease severity categories. DISCUSSION

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What is the reliability of the above estimates? The costs for the four severity levels are relatively rough. The three illness categories are derived from a survey of 234 people in an outbreak of salmonellosis caused by eating Salmonella heidelberg-contamms&ed cheddar cheese in Colorado (Cohen etal., 1978). Several sources of bias are possible: the disease severity may be higher or lower than average depending on the Salmonella serotype, the number of Salmonella ingested, and the age and sex composition of the group of people affected. To the extent this outbreak is not a "typical" salmonellosis outbreak, there is the possibility of bias. Of particular concern is the cost estimate for the mild cases because it is based on such a small sample. Mild cases are a large contributor to total costs because the vast majority of salmonellosis cases are of mild severity. Costs for deaths are reasonably reliable, yet economists still differ on the best methodology for determining these. The human capital method, evaluated at a 10% interest rate, is one fourth of the adjusted Landefeld and Seskin (1982) method used here, and the willingness to pay surveys suggest a value more than four times higher (Fisher et al., 1986, unpublished data). This paper contributes to the epidemiological literature on salmonellosis by reporting two methods for dividing cases into different severity groups: one based on surveillance data and the other on outbreak data. Future work will refine the methods for estimating the number of cases that belong in the severity categories and possibly increase the number of severity categories. Refinement of the estimated deaths is particularly important because of their large contribution to total estimated costs. The one billion dollar salmonellosis cost estimate excludes several factors that may be significant (Figure 1). Chronic medical conditions resulting from salmonellosis are excluded from the estimates. Salmonellosis is occasionally followed by chronic disease such as rheumatoid syndromes, heart disease, meningitis, colitis,

blood poisoning, or thyroiditis (Archer, 1984, 1985; Cohen and Tauxe, 1986; Mossel, 1984). What is unknown is the likelihood of occurrence. Archer (1985, 1987) has estimated that 2% of salmonellosis patients will end up with reactive arthritis, an inflammation of the joints that lasts from a few days to 6 mo. A fraction of these cases develop rheumatoid arthritis, a life-long inflammation of the joints. Rheumatoid arthritis sufferers were willing to pay 22% of household income to be rid ofarthritis in a recent survey (Thompson, 1986). With better incidence data, these increased medical costs could be added into the estimate of medical costs associated with salmonellosis. Other costs to individuals are excluded. For example, a Canadian economist, Leo Curtin (1984), estimated that the loss of leisure time was greater than the loss of worktime due to salmonellosis. Estimates using his methodology of valuing leisure time at the prevailing wage rate would more than double the cost of salmonellosis estimates presented here. An estimate for inconvenience, pain, and other relatively intangible costs to individuals could be approximated by the compensation approved by Circuit Judge John Breen, Jr. for the Chicago salmonellosis victims (Food Chemical News, 1987). Those sick 3 to 4 days are to receive $1,000 plus compensation for medical expenses and lost work time. Those sick 1 or 2 days will receive $800 plus the compensation. Individual settlements are to be negotiated for those sick longer than 4 days. Salmonellosis can affect the productivity of poultry through deaths (McCapes, 1987) or reduced feed efficiency and reduced weight gain (Krug, 1985). Other industry costs of salmonellosis disease outbreaks include plant cleanups and product recalls. Ewen Todd (1985a,b) found that readily measurable costs associated with salmonellosis outbreaks in the food service industry ranged from $60,000 to $700,000 per outbreak whereas costs to food processors ranged from $36,000 to $3.3 million per salmonellosis outbreak. Most human cases of salmonellosis come from foodborne sources (Bryan, 1980; Cohen and Tauxe, 1986). It is encouraging that several producer groups, such as the Southeastern Poultry and Egg Association, the National Broiler Council, and the American Meat Institute are in the process of developing improved manufacturing practices to reduce Salmonella contamination levels.

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ACKNOWLEDGMENTS

Helpful comments on various drafts of the paper were received from Masao Matsumoto, David Smallwood, and Lee Christensen, all at the Economic Research Service, USDA; two anonymous reviewers in the Animal and Plant Health Inspection Services, USDA; and two anonymous reviewers from the NE-165 regional project. The author is indebted to Robert Tauxe and Caroline Ryan, both at the Centers for Disease Control, for the estimations of cases in the four disease severity categories. REFERENCES Anonymous, 1987. Miller suggests new FDA approach. Food Chem. News 29:18-21. Archer, D. L., 1984. Diarrheal episodes and diarrheal disease: acute disease with chronic implications. J. Food Prot. 47:321-328. Archer, D. L., 1985. Enteric microorganisms in rheumatoid diseases: causative agents and possible mechanisms. J. Food Prot. 48:538-545. Archer, D. L., 1987. Testimony, Senate Committee on Agriculture, Nutrition, and Forestry, Full Committee Hearing on "Foodborne illnesses and deaths in the United States," Washington, DC, June 4. US Gov. Print. Off., Washington, DC. Bennett, J. V., S. D. Holmberg, M. F. Rogers, and S. L. Solomon, 1987. Infectious and parasitic diseases. Pages 102-114 in: Closing the Gap: The Burden of Unnecessary Illness. R. W. Amler and H. B. Dull, ed. Oxford Univ. Press, New York, NY.

Bureau of Labor Statistics, 1987. Consumer Price Index. Bureau of Labor Statistics, Dept. of Labor, Washington, DC. Bryan, F. L., 1980. Foodborne disease in the United States associated with meat and poultry. J. Food Prot. 43:140-150. Cohen, M. L., R. E. Fountaine, and R. E. Pollard, 1978. An assessment of patient-related economic costs in an outbreak of salmonellosis. N. Engl. J. Med. 299:459460. Cohen, M. L., and R. V. Tauxe, 1986. Drug-resistant Salmonella in the United States: an epidemiological perspective. Science 234:964-969. Cooper, B. S., and D. P. Rice, 1976. The economic cost of illness revisited. Soc. Security Bull. Feb:21-36. Curtin, L., 1984. Economic study of salmonella poisoning and control measures in Canada. Working paper no. 11/84. Marketing and Economics Branch, Agriculture Canada, Ottawa, Canada. Food Chemical News, 1987. Judge approves settlement plan for Salmonella victims. Nov 30:37. Krug, W., 1985. Social costs of Salmonella infections in humans and domestic animals. Pages 304-307 in: Proc. Int. Symp. on Salmonellosis. H. G. Snoyenbos, ed. Am. Assoc. Avian Pathol., Kennett Square, PA. Landefeld, J. S., and E. P. Seskin, 1982. The economic value of life: linking theory to practice. Am. J. Public Health 72:555-566. McCapes, R. H., 1987. Why the crisis? Poultry Processing. August: Pages 24-30. Mossel, D.A.A., 1984. Intervention as the rational approach to control diseases of microbial etiology transmitted by foods. J. Food Safety 6:89-104. Mulder, R.W.A.W., 1982. Salmonella radiciation of poultry carcasses. Ph.D. Diss. Agricultural Univ., Wageninen, The Netherlands. National Research Council, 1983. Risk-assessment in the Federal Government: Managing the Process. Natl. Acad. Press, Washington, DC. National Research Council, 1985. Meat and Poultry Inspection: the Scientific Basis of the Nation's Program. Natl. Acad. Press, Washington, DC. National Research Council, 1987. Poultry Inspection: the Basis for a Risk-Assessment System. Natl. Acad. Press, Washington, DC. Public Health Service, US Dept. of Health and Human Services, 1984. Vital Statistics of the United States, 1979. In: Mortality, Vol. II. Part A. Natl. Cent, for Health Stat., Hyattsville, MA. Roberts, T., 1985. Microbial pathogens in raw pork, chicken, and beef: benefit estimates for control using irradiation. Am. J. Agric. Econ. 67:957-965. Thompson, M. S., 1986. Willingness to pay and accept risks to cure chronic disease. Am. J. Public Health 76:390-396. Todd, E. C., 1985a. Economic loss from foodborne disease and non-illness related recalls because of mishandling by food processors. J. Food Prot. 48:621-633. Todd, E. C., 1985b. Economic loss from foodborne disease outbreaks associated with foodservice establishments. J. Food Prot. 48:169-180.

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Researchers also need to follow the charge of the National Academy of Sciences to conduct rigorous risk assessments to better quantify the economic tradeoffs for controlling salmonellosis. Reducing pathogen contamination in foods costs money. It may require changing animal husbandry practices, purchasing Salmonella-free feed, installing better refrigeration in meat coolers, reducing cross-contamination along the slaughter line, throwing out over-age food sooner in grocery stores and restaurants, teaching food preparers about proper food handling and sanitation techniques, or implementing new technologies such as irradiation of packaged poultry to kill Salmonella (Curtin, 1984; Roberts, 1985;McCapes, 1987). It is not known yet which combination of strategies will have the greatest payoff in reducing foodborne salmonellosis.

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