United States General Accounting Office

GAO Report to Congressional Committees

May 1996 FOOD SAFETY

Information on

Foodborne Illnesses

G O A

years

1921 - 1996

GAO/RCED-96-96

GAO United States

General Accounting Office

Washington, D.C. 20548

Resources, Community, and

Economic Development Division

B-270753 

May 8, 1996

Congressional Committees

Over the past decade, a number of widely reported outbreaks of

foodborne illnesses caused by microbial contamination—the most

commonly identified cause of such outbreaks—have heightened the

public’s concern about the safety of food. While such outbreaks have

brought the issue to the public’s attention, public health and food safety

officials agree that the largest number of foodborne illnesses occur as

isolated cases, not as part of a publicized outbreak.

Given the scale of the U.S. food production and distribution system and

the lack of control over how consumers handle food after they purchase it,

there is little likelihood that foodborne illnesses can be completely

eliminated. The most that can be hoped for is that all reasonable steps are

taken to ensure that the problem is minimized. In this context, we have

attempted in this report to provide a factual picture on the extent of

foodborne illness in the United States today. Specifically, we obtained the

best available information on the (1) frequency of foodborne illness,

(2) health consequences and economic impacts of foodborne illnesses,

and (3) adequacy of knowledge about foodborne illnesses to develop

effective control strategies.

Results in Brief Data on the extent of foodborne illnesses and related deaths are

incomplete and may understate the extent of the problem because most

cases go unreported. However, according to the best available estimates

by the Centers for Disease Control and Prevention and other public health

and food safety experts, millions of illnesses and thousands of deaths each

year in the United States can be traced to contaminated food. Moreover,

public health officials believe that the risk of foodborne illnesses has been

increasing over the last 20 years.

Although foodborne illnesses generally cause temporary disorders of the

digestive tract, they can also lead to more serious consequences. While the

precise cost of foodborne illnesses is unknown, recent estimates range

from over $5 billion to more than $22 billion annually. According to U.S.

Department of Agriculture estimates, the cost of medical treatment and

lost productivity related to foodborne illnesses from seven of the most

harmful bacteria may have been as much as $9.4 billion during 1993.

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Public health and food safety officials believe that current data on

foodborne illnesses do not provide a complete picture of the risk level and

do not depict the sources of contamination and the populations most at

risk in sufficient detail. More uniform and comprehensive data on the

number and causes of foodborne illnesses could form the basis of more

effective control strategies. In 1995, federal and state agencies began steps

to collect such data in five areas across the country. Federal officials

expressed some concern about whether, in this era of budget constraints,

they would be able to continue funding this discretionary effort for the

number of years needed to collect meaningful trend data.

Background The Centers for Disease Control and Prevention (CDC) is the federal

agency primarily responsible for monitoring the incidence of foodborne

illness in the United States. In collaboration with state and local health

departments and other federal agencies, CDC investigates outbreaks of

foodborne illnesses and supports disease surveillance, research,

prevention efforts, and training related to foodborne illnesses. CDC

coordinates its activities concerning the safety of the food supply with the

Food and Drug Administration (FDA) in the Department of Health and

Human Services and those concerning the safety of meat, poultry, and

eggs with the Food Safety and Inspection Service (FSIS) in the U.S.

Department of Agriculture (USDA). FDA and FSIS, which are the primary

federal agencies responsible for overseeing the safety of the food supply,

maintain liaison with CDC in Atlanta, Georgia.

CDC monitors individual cases of illness from harmful bacteria, viruses,

chemicals, and parasites (hereafter referred to collectively as pathogens)

that are known to be transmitted by foods, as well as foodborne

outbreaks,1

 through reports from state and local health departments, FDA,

and FSIS. CDC does not have the authority to require states to report data on

foodborne illnesses. In practice, each state determines which diseases it

will routinely report to CDC. In addition, state laboratories voluntarily

report the number of positive test results for several diseases that CDC has

chosen to monitor. However, these reports do not identify the source of

infection and are not limited to cases of foodborne illness. CDC also

investigates a limited number of more severe or unusual outbreaks when

state authorities request assistance. (For a description of the data that CDC

relies on to monitor foodborne illnesses, see app. I.)

1

For most pathogens, CDC defines an outbreak of foodborne illness as two or more persons

experiencing a similar illness for which a common food was implicated.

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At least 30 pathogens are associated with foodborne illnesses. For

reporting purposes, CDC categorizes the causes of outbreaks of foodborne

illnesses as bacterial, chemical, viral, parasitic, or unknown pathogens.

(See app. II. for information on these pathogens and the illnesses they

cause.) Although many people associate foodborne illnesses primarily

with meat, poultry, eggs, and seafood products, many other foods,

including milk, cheese, ice cream, orange and apple juices, cantaloupes,

and vegetables, have also been involved in outbreaks during the last

decade.

Bacterial pathogens are the most commonly identified cause of outbreaks

of foodborne illnesses. Bacterial pathogens can be easily transmitted and

can multiply rapidly in food, making them difficult to control. CDC has

targeted four of them—E. coli O157:H7, Salmonella Enteritidis, Listeria

monocytogenes, and Campylobacter jejuni—as those of greatest concern.

(See app. III.) CDC is also concerned about other bacterial pathogens, such

as Vibrio vulnificus and Yersinia enterocolitica, which can cause serious

illnesses, and Clostridium perfringens and Staphylococcus aureus, which

cause less serious illnesses but are very common. The chemical causes of

foodborne illnesses are primarily natural toxins that occur in fish or other

foods but also include heavy metals, such as copper and cadmium. Viral

pathogens are often transmitted by infected food handlers or through

contact with sewage. Only a few viral pathogens, such as the Hepatitis A

and Norwalk viruses, have been proven to cause foodborne illnesses.

Finally, parasitic pathogens, such as Trichinella—found in undercooked or

raw pork—multiply only in host animals, not in food. CDC officials believe

that viral and parasitic pathogens are less likely than bacterial pathogens

to be identified as the source of an outbreak of foodborne illness because

their presence is more difficult to detect.

Foodborne Illnesses

Are Believed to Be a

Growing Problem

The existing data on the extent of foodborne illnesses have weaknesses

and may not fully depict the extent of the problem. Public health experts

believe that the majority of cases of foodborne illness are not reported

because the initial symptoms of most foodborne illnesses are not severe

enough to warrant medical attention, the medical facility or state does not

report such cases, or the illness is not recognized as foodborne. However,

according to the best available estimates, based largely on CDC’s data,

millions of people become sick from contaminated food each year, and

several thousand die. In addition, public health and food safety officials

believe that the risk of foodborne illnesses is increasing for several

reasons. For example, as a result of large-scale food production and broad

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distribution of products, those products that may be contaminated can

reach a great number of people in many locations. Furthermore, new and

more virulent strains of previously identified harmful bacteria have been

identified in the past several decades. Also, mishandling or improper

preparation can further increase the risk.

Available Estimates Show

That Millions Are Affected

by Foodborne Illnesses

Between 6.5 million and 81 million cases of foodborne illness and as many

as 9,100 related deaths occur each year, according to the estimates

provided by several studies conducted over the past 10 years. Table 1

shows the range of estimates from four studies cited by food safety

experts as among the best available estimates on the subject. The table

also identifies the data on which these estimates are based. While various

foods have been implicated as vehicles for pathogens in foodborne

illnesses and related deaths, the available data do not allow a precise

breakdown by specific foods. In general, animal foods—beef, pork,

poultry, seafood, milk, and eggs—are more frequently identified as the

source of outbreaks in the United States than non-animal foods. USDA,

which regulates meat and poultry products, has estimated that over half of

all foodborne illnesses and deaths are caused by contaminated meat and

poultry products.

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Table 1: Estimates of Foodborne Illnesses and Related Deaths

Study or report/authors (year)

Estimated number of

illnesses per year

Estimated number of

deaths per year Basis for estimates

The Incidence and Cost of

Foodborne Diarrheal Disease in

the United States, Archer and

Kvenberg (1985)a

24 million to 81 million or more No estimate provided National survey of physicians

conducted by National Center

for Health Statistics (1977-78),

supplemented with 1983 data

on illnesses from specific

pathogens

Closing the Gap: The Burden of

Unnecessary Illness, Bennett

et. al. (1987)b

6.5 million annually 9,100 Published and survey data

from National Center for Health

Statistics, Center for Infectious

Diseases, and the Center for

Prevention Services

Preliminary Estimates of Costs of

Foodborne Disease in the United

States, Todd (1989)c

12.6 million 523 Median of four estimates

based on (1) CDC outbreak

data; (2) 1987 Bennett study

data; (3) Salmonella

underreporting; and (4)

Canadian disease rates

extrapolated to U.S. population

Foodborne Pathogens: Risks and

Consequences, Council for

Agricultural Science and

Technology (1994)d

6.5 million to 33 million Up to 9,000 Review of past studies

aJournal of Food Protection, Vol. 48, No. 10 (Oct. 1985), pp. 887-894.

bNew York: Oxford University Press.

cJournal of Food Protection, Vol. 52, No. 8 (Aug. 1989), pp. 586-601.

dNo. 122, Sept. 1994. Ames, Iowa: Council for Agricultural Science and Technology.

The wide range in the estimated number of foodborne illnesses and related

deaths is due primarily to the considerable uncertainty about the number

of cases that are never reported to CDC and the methodology used to make

the estimate. Public health and food safety officials believe that many of

these illnesses are not reported because the episodes are mild and do not

require medical treatment. For example, CDC officials believe that many

intestinal illnesses that are commonly referred to as the stomach flu are

caused by foodborne pathogens. According to these officials, people do

not usually associate these illnesses with food because the onset of

symptoms occurs 2 or more days after the contaminated food was eaten.

In other cases, a foodborne illness may contribute to the death of an

already ill person. In these cases, a foodborne illness may not be reported

as the cause of death. In the absence of more complete reporting,

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researchers can only broadly estimate the number of illnesses and related

deaths.

Furthermore, most physicians and health professionals treat patients who

have diarrhea without ever identifying the specific cause of the illness. In

severe or persistent cases, a laboratory test may be ordered to identify the

responsible pathogen. However, some laboratories may not have the

ability to identify a given pathogen.

Finally, physicians may not associate the symptoms they observe with a

pathogen that they are required to report to the state or local health

authorities. For example, a CDC official cited a Nevada outbreak in which

no illnesses from E. coli O157:H7 had been reported to health officials,

despite a requirement that physicians report such cases to the state health

department.2

 Nevertheless, 58 illnesses from this outbreak were identified

after public service announcements alerted the public and health

professionals that contaminated hamburger had been shipped to

restaurants in a specific area of the state.

Experts Believe That the

Risk of Foodborne

Illnesses Is Increasing

Food safety and public health officials believe that the risk of foodborne

illnesses is increasing. Several factors contribute to this increased risk.

First, the food supply is changing in ways that can promote foodborne

illnesses. For example, as a result of modern animal husbandry

techniques, such as crowding a large number of animals together, the

pathogens that can cause foodborne illnesses in humans can spread

throughout the herd. Because of broad distribution, contaminated

products can reach individuals in more locations. Mishandling of food can

also lead to contamination. For example, leaving perishable foods at room

temperature increases the likelihood of bacterial growth, and improper

preparation, such as undercooking, reduces the likelihood that bacteria

will be killed and can further increase the risk of illness. There are no

comprehensive data to explain at what point pathogens are introduced

into foods. Knowledgeable experts believe that although illnesses and

deaths often result after improper handling and preparation, the pathogens

were, in many cases, already present at the processing stage. Furthermore,

the pathogens found on meat and poultry products may have arrived on

the live animals.

Second, because of demographic changes, more people are at greater risk

of contracting a foodborne illness. Certain populations are at greater risk

2

These cases were part of the 1993 outbreak in the western United States.

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for these illnesses: people with suppressed immune systems, children, and

the elderly. In addition, children are more at risk because group settings,

such as day care centers, increase the likelihood of person-to-person

transmission of pathogens. The number of children in these settings is

increasing, as is the number in other high-risk groups, according to CDC.

Third, three of the four pathogens CDC considers the most important were

unrecognized as causes of foodborne illness 20 years

ago—Campylobacter, Listeria, and E. coli O157:H7.

Fourth, bacteria already recognized as sources of foodborne illnesses have

found new modes of transmission. While many illnesses from E. coli

O157:H7 occur from eating insufficiently cooked hamburger, these

bacteria have also been found more recently in other foods, such as

salami, raw milk, apple cider, and lettuce. Other bacteria associated with

contaminated meat and poultry, such as Salmonella, have also been found

in foods that the public does not usually consider to be a potential source

of illness, such as ice cream, tomatoes, melons, alfalfa sprouts, and orange

juice.

Fifth, some pathogens are far more resistant than expected to

long-standing food-processing and storage techniques previously believed

to provide some protection against the growth of bacteria. For example,

some bacterial pathogens, such as Yersinia and Listeria, can continue to

grow in food under refrigeration.

Finally, according to CDC officials, virulent strains of well-known bacteria

have continued to emerge. For example, one such pathogen, E. coli

O104:H21, is another potentially deadly strain of E. coli. In 1994, CDC found

this new strain in milk from a Montana dairy.

Foodborne Illnesses

Can Be Debilitating

and Costly

While foodborne illnesses are often temporary, they can also result in

more serious illnesses requiring hospitalization, long-term disability, and

death. Although the overall cost of foodborne illnesses is not known, two

recent estimates place some of the costs in the range of $5.6 billion to

more than $22 billion per year. The first estimate, covering only the

portion related to the medical costs and productivity losses of seven

specific pathogens, places the costs in the range of $5.6 billion to

$9.4 billion. The second, covering only the value of avoiding deaths from

five specific pathogens, places the costs in the range of $6.6 billion to

$22 billion.

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Pathogens Cause Disabling

Health Effects in Some

People

While foodborne illnesses are often brief and do not require medical

treatment, they can also result in more serious illnesses and death. In a

small percentage of cases, foodborne infections spread through the

bloodstream to other organs, resulting in serious long-term disability or

even death. Serious complications can also result when diarrhetic

infections resulting from foodborne pathogens act as a triggering

mechanism in susceptible individuals, causing an illness such as reactive

arthritis to flare up. In other cases, no immediate symptoms may appear,

but serious consequences may eventually develop. The likelihood of

serious complications is unknown, but some experts estimate that about 2

to 3 percent of all cases of foodborne illness lead to serious consequences.

For example:

• E. coli O157:H7 can cause kidney failure in young children and infants and

is most commonly transmitted to humans through the consumption of

undercooked ground beef. The largest reported outbreak in North America

occurred in 1993 and affected over 700 people, including many children

who ate undercooked hamburgers at a fast food restaurant chain.

Fifty-five patients, including four children who died, developed a severe

disease, Hemolytic Uremic Syndrome, which is characterized by kidney

failure.

• Salmonella can lead to reactive arthritis, serious infections, and deaths. In

recent years, outbreaks have been caused by the consumption of many

different foods of animal origin, including beef, poultry, eggs, milk and

dairy products, and pork. The largest outbreak, occurring in the Chicago

area in 1985, involved over 16,000 laboratory-confirmed cases and an

estimated 200,000 total cases. Some of these cases resulted in reactive

arthritis. For example, one institution that treated 565 patients from this

outbreak confirmed that 13 patients had developed reactive arthritis after

consuming contaminated milk. In addition, 14 deaths may have been

associated with this outbreak.

• Listeria can cause meningitis and stillbirths and has a fatality rate of 20 to

40 percent.3

 All foods may contain these bacteria, particularly poultry and

dairy products. Illnesses from this pathogen occur mostly in single cases

rather than in outbreaks. The largest outbreak in North America occurred

in 1985 in Los Angeles, largely in pregnant women and their fetuses. More

than 140 cases of illness were reported, including at least 13 cases of

meningitis. At least 48 deaths, including 20 stillbirths or miscarriages, were

attributed to the outbreak. Soft cheese produced in a contaminated factory

environment was confirmed as the source.

3

Fatalities as a percentage of all cases of illness.

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• Campylobacter may be the most common precipitating factor for

Guillain-Barre syndrome, which is now one of the leading cause of

paralysis from disease in the United States. Campylobacter infections

occur in all age groups, with the greatest incidence in children under 1

year of age. The vast majority of cases occur individually, primarily from

poultry, not during outbreaks. Researchers estimate that 4,250 cases of

Guillain-Barre syndrome occur each year and that about 425 to 1,275 of

these cases are preceded by Campylobacter infections.

Foodborne Illnesses Can

Cost Billions of Dollars in

Medical Expenses and Lost

Productivity Annually

While the overall annual cost of foodborne illnesses is unknown, the

studies we reviewed estimate that it is in the billions of dollars. The range

of estimates among the studies is wide, however, principally because of

uncertainty about the number of cases of foodborne illness and related

deaths. (See app. IV.) Other differences stem from the differences in the

analytical approach used to prepare the estimate. Some economists

attempt to estimate the costs related to medical treatment and lost wages

(the cost-of-illness method); others attempt to estimate the value of

reducing the incidence of illness or loss of life (the willingness-to-pay

method). Two recent estimates demonstrate these differences in analytical

approach.

In the first, USDA’s Economic Research Service (ERS) used the

cost-of-illness approach to estimate that the 1993 medical costs and losses

in productivity resulting from seven major foodborne pathogens ranged

between $5.6 billion and $9.4 billion.4

 Of these costs, $2.3 billion to

$4.3 billion were the estimated medical costs for the treatment of acute

and chronic illnesses, and $3.3 billion to $5.1 billion were the productivity

losses from the long-term effects of foodborne illnesses. Medical expenses

ranged from more modest expenses for routine doctors’ visits and

laboratory tests to more substantial expenses for hospital rooms and

kidney transplants. Productivity losses included expenses such as lost

wages from long-term disabilities and deaths caused by foodborne

illnesses. Table 2 provides information on the costs associated with each

of the seven pathogens.

4

“Pathogen Reduction, Hazard Analysis and Critical Control Point (HACCP) Systems,” Federal Register

(Feb. 3, 1995).

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Table 2: ERS’ Estimated Medical Costs

and Productivity Losses From

Illnesses Caused by Seven Foodborne

Pathogens During 1993

Dollars in billions

Pathogens Medical costs

Productivity

lossesa

Total costs

and losses

Campylobacter jejuni or coli $0.6-0.8 $0.0b-0.2 $0.6-1.0

Clostridium perfringens 0.1c Not available 0.1

E. coli O157:H7 0.0a-0.1 0.2-0.5 0.2-0.6

Listeria monocytogenes 0.1 0.1-0.2 0.2-0.3

Salmonella 0.4-2.0 0.2-1.5 0.6-3.5

Staphylococcus aureus 1.2c Not available 1.2

Toxoplasma gondii 0.0b 2.7 2.7

Total $2.3d-4.3 $3.3d-5.1 $5.6-9.4

aThe productivity losses for E. coli O157:H7, Listeria monocytogenes, and Toxoplasma gondii

included costs related to long-term disabilities and deaths. Productivity losses for Campylobacter

and Salmonella were calculated for deaths only.

bThese amounts are less than $50 million.

cBased on average costs and included some productivity losses in addition to medical costs.

dDoes not add due to rounding.

Source: ERS and FSIS.

CDC, FDA, and ERS economists stated that these estimates may be low for

several reasons. First, the cost-of-illness approach generates low values

for reducing health risks to children and the elderly because these groups

have low earnings and hence low productivity losses. Second, this

approach does not recognize the value that individuals may place on (and

pay for) feeling healthy, avoiding pain, or using their free time. In addition,

not all of the 30 pathogens associated with foodborne illnesses were

included.

In the second analysis,5 ERS used the willingness-to-pay method6

 to

estimate the value of preventing deaths for five of the seven major

pathogens (included in the first analysis) at $6.6 billion to $22.0 billion in

1992. The estimate’s range reflected the range in the estimated number of

deaths, 1,646 to 3,144, and the range in the estimated value of preventing a

death, $4 million to $7 million. Although these estimated values were

higher than those resulting from the first approach, they may have also

understated the economic cost of foodborne illnesses because they did not

5

Aldrich, Lorna. “Food-Safety Policy: Balancing Risk and Costs,” Food Review. USDA, Economic

Research Service, Vol. 17, Issue 2, May-Aug. 1994, pp. 10-11.

6

ERS also refers to the willingness-to-pay approach as the value of reducing the risk of illness or death.

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include an estimate of the value of preventing nonfatal illnesses and

included only five of the seven major pathogens included in the first

analysis.

Better Data Could

Lead to More

Effective Control

Strategies

While current data indicate that the risk of foodborne illnesses is

significant, public health and food safety officials believe that these data

do not identify the level of risk, the sources of contamination, and the

populations most at risk in sufficient detail. More uniform and

comprehensive data on the number and causes of foodborne illnesses

could form the basis of more effective control strategies. Beginning in

1995, federal and state agencies took steps to collect such data in five

areas across the country. While this effort will provide additional data, CDC

officials believe that collecting data at more locations and for other

pathogens would provide even more representative data and identify more

causes of foodborne illnesses.

Current Data Do Not

Provide Sufficient Detail

on the Risk Posed by

Foodborne Illnesses

According to public health and food safety officials, the current voluntary

reporting system does not provide sufficient data on the prevalence and

sources of foodborne illnesses. There are no specific national

requirements for reporting on foodborne pathogens. According to CDC,

states do not (1) report on all pathogens of concern, (2) usually identify

whether food was the source of the illness, or (3) identify many of the

outbreaks or individual cases of foodborne illness that occur.

Consequently, according to CDC, FDA, and FSIS, public health officials

cannot precisely determine the level of risk from known pathogens or be

certain that they can detect the existence and spread of new pathogens in

a timely manner. They also cannot identify all factors that put the public at

risk or all types of food or situations in which microbial contamination is

likely to occur. Finally, without better data, regulators cannot assess the

effectiveness of their efforts to control the level of pathogens in food.

According to public health and food safety officials, a better system for

monitoring the extent of foodborne illnesses would actively seek out

specific cases. Such a system would require outreach to physicians and

clinical laboratories. CDC demonstrated the effectiveness of such an

outreach effort when it conducted a long-term study, initiated in 1986, to

determine the number of cases of illness caused by Listeria. This study

showed that a lower rate of illness caused by Listeria occurred between

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1989 and 1993 during the implementation of food safety programs

designed to reduce the prevalence of Listeria in food.

Efforts to Improve

Information on Foodborne

Illnesses Are Under Way

In July 1995, CDC, FDA, and FSIS began a comprehensive effort to track the

major bacterial pathogens that cause foodborne illnesses. These agencies

are collaborating with state health departments in five areas across the

country to better determine the incidence of infection with Salmonella and

E. coli O157:H7 and other foodborne bacteria and to identify these sources

of diarrheal illness from Salmonella and E. coli O157:H7.7

 Initially, FDA

provided $378,000 and FSIS provided $500,000 through CDC to the five

locations for 6 months. The agencies believe that this effort should be a

permanent part of a sound public health system. For fiscal year 1996, FSIS

is providing $1 million and FDA is providing $300,000. CDC provides overall

management and coordination and facilitates the development of technical

expertise at the sites through its established relationships with the state

health departments.

The project consists of three parts:

• a survey of the local population in the five locations and interviews with

local health professionals to estimate the number of diarrheal illnesses and

determine the number of illnesses for which medical attention was sought

and laboratory samples were taken;

• a survey of laboratories to determine the microbiological testing

procedures and processes used to identify foodborne illnesses and an

audit of the participating laboratories’ test results to determine what

proportion of cases were detected; and

• statistical studies to determine, among other things, the risks associated

with different foods.

CDC and the five sites will use the information to identify emerging

foodborne pathogens and monitor the incidence of foodborne illness. FSIS

will use the data to evaluate the effectiveness of new food safety programs

and regulations to reduce foodborne pathogens in meat and poultry and

assist in future program development. FDA will use the data to evaluate its

efforts to reduce foodborne pathogens in seafood, dairy products, fruit,

and vegetables.

7

The areas are (1) the greater metropolitan area of Atlanta, (2) an area comprised by two northern

California counties, (3) an area comprised by two Connecticut counties, (4) the state of Minnesota,

and (5) the state of Oregon.

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According to CDC, FDA, and FSIS officials, such projects must collect data

over a number of years to identify national trends and evaluate the

effectiveness of strategies to control pathogens in food. Funding was

decreased slightly for this project in 1996, and these officials are

concerned about the continuing availability of funding, in this era of

budget constraints, to conduct this discretionary effort over the longer

term.

Agency Comments We provided copies of a draft of this report to CDC, FSIS, and FDA for their

review and comment. We met with the Director, Division of Bacterial and

Mycotic Diseases, CDC; the Associate Administrator, FSIS; and other

relevant officials from both agencies. These officials generally agreed with

the information discussed and provided some clarifying comments that we

incorporated into the report. FDA’s Office of Legislative Affairs notified us

that FDA generally agreed with the contents of the report and provided

several technical comments that we incorporated.

Scope and

Methodology

To conduct this review, we spoke with, and obtained studies, data, and

other information on foodborne illnesses from, officials at CDC, ERS, FDA,

and FSIS. We met with these officials at their headquarters in Atlanta,

Georgia, and Washington, D.C. To examine the frequency of foodborne

illness, we met with agency officials to identify and discuss the most

widely recognized studies on the incidence of foodborne illness in the

United States and obtained documentation. To examine the health

consequences of foodborne illnesses, we relied primarily on discussions

with medical experts at CDC and articles that have appeared in professional

journals obtained from CDC officials and our literature review. To examine

the economic impacts of foodborne illnesses, we reviewed the analytical

approaches used to estimate the costs of foodborne illnesses and recent

examples of such estimates and spoke with economists at CDC, ERS, and

FDA. To examine the adequacy of knowledge about foodborne illnesses to

develop effective control strategies, we spoke with the project managers

from CDC, FDA, and FSIS and other agency officials associated with a joint

effort with five state health departments recently undertaken to improve

their knowledge about foodborne illnesses and collected agency

documents.

We reviewed but did not independently verify the accuracy of the data

available on the number of reported cases of foodborne illness, the overall

estimates of incidence, or the estimates of costs from specific pathogens

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because this effort would have required the verification of multiple

databases and other information from state and federal agencies and other

sources. This verification process would have required a large

commitment of additional resources. We did not review data on the

incidence of foodborne illness in other countries because comparable data

were not readily available and the data that are available have some of the

same limitations as the data on U.S. foodborne illnesses.

We conducted our review from June 1995 through April 1996 in

accordance with generally accepted government auditing standards.

We are sending this report to you because of your role in overseeing the

activities and funding of the agencies responsible for the issues discussed.

If you or your staff have any questions about this report, I can be reached

at (202) 512-5138. Major contributors to this report are listed in appendix

V.

Robert A. Robinson

Director, Food and

 Agriculture Issues Area

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List of Congressional Committees

The Honorable Richard G. Lugar

Chairman

The Honorable Patrick J. Leahy

Ranking Minority Member

Committee on Agriculture, Nutrition,

 and Forestry

United States Senate

The Honorable Mark O. Hatfield

Chairman

The Honorable Robert C. Byrd

Ranking Minority Member

Committee on Appropriations

United States Senate

The Honorable Pat Roberts

Chairman

The Honorable E (Kika) de la Garza

Ranking Minority Member

Committee on Agriculture

House of Representatives

The Honorable Bob Livingston

Chairman

The Honorable David R. Obey

Ranking Minority Member

Committee on Appropriations

House of Representatives

Page 15 GAO/RCED-96-96 Information of Foodborne Illnesses
Contents

Letter 1

Appendix I 

Sources of Data on

Illnesses and Deaths

From Foodborne

Pathogens

18

Appendix II 

Illnesses From

Foodborne Pathogens

and Chemicals

21

Appendix III 

Estimated Number of

Illnesses and Deaths

From Four Major

Pathogens

23

Appendix IV 

Estimated Costs of

Foodborne Illnesses

29

Appendix V 

Major Contributors to

This Report

31

Tables Table 1: Estimates of Foodborne Illnesses and Related Deaths 5

Table 2: ERS’ Estimated Medical Costs and Productivity Losses

From Illnesses Caused by Seven Foodborne Pathogens During

1993

10

Table I.1: Data CDC Relies on to Monitor, Control, and Prevent

Foodborne Illnesses

18

Page 16 GAO/RCED-96-96 Information of Foodborne Illnesses
Contents

Table II.1: Some Foodborne Pathogens That Can Cause Serious

Illnesses

22

Table IV.1: Estimated Number of Illnesses and Deaths for Seven

Major Pathogens From All Sources and From Food in 1993

29

Table IV.2: “Cost-of-Illness” Estimates for Seven Major Pathogens

From All Foods and From Meat and Poultry During 1993

30

Table IV.3: “Willingness-to-Pay” Estimate for Five Major

Pathogens in 1992

30

Figures Figure I.1: Reported Cases of Illness From Foodborne Outbreaks

by Cause, 1988-91

19

Figure III.1: Reported Cases of Illness from Outbreaks of E. coli

O157:H7, 1982-95

23

Figure III.2: Number of States Requiring Reporting of E. coli

O157:H7, 1987-94

24

Figure III.3: Estimated Percentage of People Who Recover,

Remain Ill, or Die From E. coli O157:H7

25

Figure III.4: Estimated Percentage of People Who Recover or Die

From Salmonella

26

Figure III.5: Estimated Percentage of People Who Recover,

Remain Ill, or Die From Listeria monocytogenes

27

Figure III.6: Estimated Percentage of People Who Recover or Die

From Campylobacter jejuni

28

Abbreviations

CDC Centers for Disease Control and Prevention

ERS Economic Research Service

FDA Food and Drug Administration

FSIS Food Safety and Inspection Service

HUS Hemolytic Uremic Syndrome

USDA U.S. Department of Agriculture

Page 17 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix I 

Sources of Data on Illnesses and Deaths

From Foodborne Pathogens

To monitor, control, and prevent foodborne illnesses, the Centers for

Disease Control and Prevention (CDC) relies primarily on four types of data

from local and state health departments, according to CDC officials. These

four types of data are shown in table I.1.

Table I.1: Data CDC Relies on to Monitor, Control, and Prevent Foodborne Illnesses

Type Description of data Frequency of collection Purpose Limitations

Outbreak data Reports of foodborne

outbreaks from local and

state health departments

Reported annually for

most outbreaks (more

frequently for outbreaks

of E. coli O157:H7 and

Salmonella Enteritidis)

Identify new trends in

illnesses and modes and

vehicles of transmission

of pathogens

Do not include all

outbreaks or isolated

cases for most

pathogens; often, the

pathogen and the route

of infection are not

identified; delay in

compiling data

Laboratory data Computer-based

reporting on positive test

results for four

pathogens from local

and state laboratories

Usually weekly, but

varies; can be daily or

more frequently

if needed

Analysis of trends and

rapid detection of

outbreaks

Can only identify cases

for which tests were

performed; limited to four

pathogens; do not

identify source of

infection

Outbreak investigations Data CDC collects when

it provides assistance at

the request of local and

state health authorities

As requested Provide specific

information on the

pathogen and source of

infection

Only account for a

portion of the total

number of outbreaks

Active surveillance data

from laboratories,

physicians, and patients

Comprehensive data

collected from a network

of representative sites,

laboratories, physicians,

and patients

Ongoing Estimate the incidence of

illness and determine the

source of illness and the

populations affected

Until recently, few

networks had been

established for collecting

data on foodborne

illnesses because such

networks require

substantial resources

Source: Officials at the National Center for Infectious Diseases, CDC.

As table I.1 notes, each type of data has limitations, particularly the

outbreak and laboratory data, which have been CDC’s primary monitoring

tools. More specifically, in about half of the outbreaks as shown in figure

I.1, the data do not identify the agent that caused the outbreak.

Furthermore, these data generally do not provide information about the

cause of a new trend. One or more factors can account for a new trend: a

change in consumption behavior, such as a preference for turkey over red

meat; a reporting bias, such as an increase in the number of laboratories

testing for the disease; or a change in the nature of the disease, such as the

emergence of a new strain. Finally, there is a delay from the time these

data are reported to CDC until they are compiled into annual summaries. At

Page 18 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix I 

Sources of Data on Illnesses and Deaths

From Foodborne Pathogens

the time of our review, complete annual summaries of data were only

available through 1991.

Figure I.1: Reported Cases of Illness

From Foodborne Outbreaks by Cause,

1988-91

Number of Cases of Illness

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

1988 1989 1990 1991

Year

Cause not determined

Other cause

Bacteria

Note: Other causes include chemicals, viruses, and parasites.

Source: CDC.

Furthermore, CDC’s laboratory data, from its Public Health Laboratory

Information System, represent only a fraction of the cases of illnesses that

occur from four pathogens that CDC tracks.8

 For example, only one

confirmed case of infection was cited in the laboratory data that the

Georgia Health Department reported to CDC during an outbreak caused by

contaminated ice cream products in 1994. However, on the basis of a

survey of home delivery customers that it conducted, CDC estimated that

8

The four pathogens are Salmonella, Shigella, Campylobacter, and E. coli O157:H7. At least 30

pathogens are associated with foodborne illnesses.

Page 19 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix I 

Sources of Data on Illnesses and Deaths

From Foodborne Pathogens

11,404 cases occurred in Georgia alone (products were distributed in 48

states). Finally, these data do not include information about the source of

the illness.

In addition to its program activities to monitor, control, and prevent

foodborne illnesses, CDC collects national data on a range of pathogens and

illnesses from a variety of data sources. These sources include the

National Notifiable Diseases Surveillance System,9

 the National Hospital

Discharge Survey, the National Ambulatory Medical Care Survey, the

National Health Interview Survey, and the National Vital Statistics System.

Researchers use these data to estimate the number of foodborne illnesses,

their severity, and their costs. But these data have major limitations for

understanding foodborne illnesses, primarily because they rarely identify

the specific pathogen or indicate the method of transmission. For

example, illnesses, such as those caused by E.coli O157:H7,10 cannot

always be distinguished from other similar illnesses. Researchers may

supplement national data with data from health maintenance

organizations or community health studies. Such studies provide more

detailed information about foodborne illnesses but are limited to small

samples and have only been done occasionally.

9

Data from this system are the basis of CDC’s publications on the diseases reported to local and state

public health officials each week.

10E. coli O157:H7 is the strain of bacteria responsible for the 1993 outbreak from undercooked

hamburgers at a chain of restaurants in the western United States.

Page 20 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix II 

Illnesses From Foodborne Pathogens and

Chemicals

Although foodborne illnesses are often short term and do not require

medical treatment, in some cases, these illnesses can involve other organs,

resulting in serious complications. In other cases, foodborne illnesses may

not result in immediate symptoms but ultimately may produce serious

health problems.

CDC has classified the causes of foodborne illnesses into the following four

categories:

• Bacterial pathogens are microorganisms that can be seen with a

microscope but not with the naked eye. Some bacterial pathogens are

infectious themselves or can produce toxins. Furthermore, bacteria can

multiply rapidly in food, making them difficult to control and can be

transmitted through person-to-person contact. Some bacteria, such as

Clostridium botulinum, which causes botulism, can form spores in food

that can resist some food preservation treatments, including boiling.

• Chemical agents are primarily naturally occurring toxins that can enter the

food supply. Paralytic shellfish poisoning and mushroom poisoning are

caused by such chemicals. Heavy metals—such as cadmium, copper, iron,

tin, and zinc—are also included in this category. These pathogens can

cause a variety of gastrointestinal, neurologic, respiratory, and other

symptoms.

• Viral pathogens are too small to be seen with a conventional microscope.

Only a few viral pathogens, such as the Hepatitis A and Norwalk viruses,

have been proven to cause foodborne illnesses. Viral pathogens are often

transmitted by infected food handlers or through contact with sewage.

• Parasitic pathogens are larger than bacterial pathogens and include

protozoa (one-celled microorganisms) and multicelled parasites. They

multiply only in host animals, not in food. Protozoa form cysts that are

similar to spores but less resistant to heat. Cysts can be transmitted to new

hosts through food that has been eaten. Multicelled parasites, such as

Trichinella spiralis, which causes trichinosis, occur in microscopic forms,

such as eggs and larvae. Thorough cooking will destroy larvae.

While the likelihood of serious complications from foodborne illnesses is

unknown, some researchers estimate that about 2 to 3 percent of all cases

of foodborne illness lead to serious consequences. Although anyone can

suffer from foodborne illnesses, certain populations are more at risk from

them or their complications than others: pregnant women, children, those

with compromised or suppressed immune systems, and the elderly. These

groups are more at risk because of altered, underdeveloped, damaged, or

weakened immune systems.

Page 21 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix II 

Illnesses From Foodborne Pathogens and

Chemicals

Table II.1 provides information on several foodborne pathogens, the

serious complications they may result in, and some of the foods in which

they have been found.

Table II.1: Some Foodborne Pathogens That Can Cause Serious Illnesses

Foodborne pathogen Serious illnesses that can result

Foods in which pathogens have been

found

Bacteria

Campylobacter Arthritis, blood poisoning, Guillain-Barre

syndrome (paralysis), chronic diarrhea,

meningitis, and inflammation of the heart,

gallbladder, colon, and pancreas

Poultry, raw milk, and meat

E. coli O157:H7 HUS,a which is associated with kidney

failure and neurologic disorders; and

other illnesses

Meat, especially ground beef; raw milk;

and produce

Listeria Meningitis, blood poisoning, stillbirths,

and other disorders

Soft cheese, other dairy products, meat,

poultry, seafood, fruits, and vegetables

Salmonella Reactive arthritis, blood poisoning,

Reiter’s disease (inflammation of joints,

eye membranes, and urinary tract) and

inflammation of the pancreas, spleen,

colon, gallbladder, thyroid, and heart

Poultry, meat, eggs, dairy products,

seafood, fruits, and vegetables

Shigella Reiter’s disease, HUS, pneumonia, blood

poisoning, neurologic disorders, and

inflammation of the spleen

Salads, milk and dairy products, and

produce

Vibrio vulnificus Blood poisoning Seafood

Yersinia enterocolitica Reiter’s disease, pneumonia, and

inflammation of vertebrae, lymphatic

glands, liver, and spleen

Pork and dairy products

Parasites

Toxoplasma gondii Central nervous system disorders Meat, primarily pork

Trichinella spiralis Heart and neurologic disorders Pork

aHemolytic-uremic syndrome.

Source: CDC, Food and Drug Administration, U.S. Department of Agriculture, and Council for

Agricultural Science and Technology.

Page 22 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix III 

Estimated Number of Illnesses and Deaths

From Four Major Pathogens

In 1990, the Public Health Service identified E. coli O157:H7, Salmonella,

Listeria monocytogenes and Campylobacter jejuni as the four most

important foodborne pathogens in the United States because of the

severity and the estimated number of illnesses they cause. According to

CDC officials, illnesses caused by E. coli O157:H7 and Listeria

monocytogenes are generally more deadly than illnesses caused by other

foodborne pathogens. In contrast, illnesses caused by Salmonella and

Campylobacter jejuni are less likely to be deadly but are more common.

This appendix discusses the estimated number of cases of foodborne

illness caused by these pathogens.

E. coli O157:H7 E. coli O157:H7 has emerged as an important cause of outbreaks of

foodborne illness in the United States since 1982. (See fig. III.1).

Figure III.1: Reported Cases of Illness from Outbreaks of E. coli O157:H7, 1982-95

Number of Cases

0

100

200

300

400

500

600

700

800

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

Year

Notes: 1995 data are preliminary. Approximately 66 percent of the outbreaks from 1982-85 were

foodborne. The remaining outbreaks include those from other routes of infection, such as

person-to-person contact, or were unidentified and may also be related to contaminated food.

Source: CDC.

Page 23 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix III 

Estimated Number of Illnesses and Deaths

From Four Major Pathogens

Because few laboratories in the United States routinely test for E. coli

O157:H7, the actual number of illnesses caused by this pathogen is

unknown, but CDC officials estimate that this pathogen causes

approximately 21,000 illnesses annually. As shown in figure III.2, only 33

states required reporting of such illnesses through the end of 1994,

according to information provided by CDC.

Figure III.2: Number of States

Requiring Reporting of E. coli O157:H7,

1987-94

Number of States

0

5

10

15

20

25

30

35

1987 1988 1989 1990 1991 1992 1993 1994

Year

Source: CDC.

Figure III.3 provides estimates of the percentage of people who recover,

remain ill, or die from E. coli O157:H7.

Page 24 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix III 

Estimated Number of Illnesses and Deaths

From Four Major Pathogens

Figure III.3: Estimated Percentage of

People Who Recover, Remain Ill, or Die

From E. coli O157:H7

50.0% • Do Not Visit Physician and

Recover Fully

32.0%•

Visit Physician and Recover Fully

•15.4%

Hospitalized and Recover Fully

•

2.3%

Hospitalized and Die

0.3%

Hospitalized and Develop Chronic

Kidney Failure

Source: Estimated by USDA’s Economic Research Service on the basis of information from CDC

and other sources.

Salmonella On the basis of population-based studies, CDC officials estimate that

between 800,000 and 4 million illnesses from the more than 2,000 strains of

Salmonella occur each year in the United States. In 1994, one strain,

Salmonella Enteritidis, accounted for more than 25 percent of all reported

infections from Salmonella. Confirmed laboratory reports of the

Salmonella Enteritidis strain increased from 3,322 to 10,009 between 1982

to 1994. While the number of outbreaks from Salmonella Enteritidis has

declined since 1989, over 5,000 people, more than in any other year,

became ill from the 44 outbreaks reported in 1994.

Figure III.4 shows the estimated percentage of people who recover or die

from all strains of Salmonella.

Page 25 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix III 

Estimated Number of Illnesses and Deaths

From Four Major Pathogens

Figure III.4: Estimated Percentage of

People Who Recover or Die From

Salmonella

93.0% • Do Not Visit Physician and

Recover Fully

•

5.0%

Visit Physician and Recover Fully

1.9%

Hospitalized and Recover Fully

0.1%

Hospitalized and Die

Source: Estimated by USDA’s Economic Research Service on the basis of information from CDC

and other sources.

Listeria monocytogenes CDC estimates that the number of illnesses and deaths caused by Listeria

monocytogenes declined between 1989 and 1993, from 1,965 cases and 481

deaths to 1,092 cases and 248 deaths. CDC attributes this downward trend

to prevention efforts implemented by the food industry and regulatory

agencies. Figure III.5 shows the estimated percentages of people who

recover, remain ill, or die from Listeria monocytogenes.

Page 26 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix III 

Estimated Number of Illnesses and Deaths

From Four Major Pathogens

Figure III.5: Estimated Percentage of

People Who Recover, Remain Ill, or Die

From Listeria monocytogenes

15.5% 61.0% • Hospitalized and Recover Fully •

Hospitalized and Develop Chronic

Complications

•23.5%

Hospitalized and Die

Source: Estimated by USDA’s Economic Research Service on the basis of information from CDC

and other sources.

Campylobacter jejuni According to CDC, Campylobacter jejuni is the most common bacterial

cause of diarrhea in the industrialized world. An estimated 2 million to

4 million cases occur each year in the United States, according to

population-based studies. Although the number of Campylobacter jejuni

cases confirmed by laboratory reports represents only a small proportion

of the total number of illnesses that are estimated to occur from

Campylobacter jejuni, the reported number more than doubled from 3,947

in 1982 to 7,970 in 1989. Most cases of illness occur sporadically and not as

part of an outbreak. Illness can occur from contact with raw foods (often

poultry) during food preparation. Figure III.6 shows the estimate of the

percentage of people who recover or die from Campylobacter jejuni.

Page 27 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix III 

Estimated Number of Illnesses and Deaths

From Four Major Pathogens

Figure III.6: Estimated Percentage of

People Who Recover or Die From

Campylobacter jejuni

94.00% • Do Not Visit Physician and

Recover Fully

•

5.40%

Visit Physician and Recover Fully

0.57%

Hospitalized and Recover Fully

0.03%

Hospitalized and Die

Source: Estimated by USDA’s Economic Research Service on the basis of information from CDC

and other sources.

Page 28 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix IV 

Estimated Costs of Foodborne Illnesses

This appendix provides information on the cost of foodborne illnesses

using both the cost-of-illness and the willingness-to-pay methods. The

range of estimates is wide, however, principally because of uncertainty

over the number of cases of foodborne illness and deaths.

Table IV.1 provides the estimated number of illnesses and deaths in 1993

used to calculate the cost-of-illness estimate. As the table indicates, food

was the most frequent source of contamination for five of the seven

pathogens the U.S. Department of Agriculture’s (USDA) Economic Research

Service examined. CDC has targeted four of these seven pathogens as the

most threatening foodborne pathogens.

Table IV.1: Estimated Number of Illnesses and Deaths for Seven Major Pathogens From All Sources and From Food in 1993

All sources Food

Pathogens

Estimated

number of

illnesses

Estimated

number of

deaths

Estimated

percentage

Estimated

number of

illnesses

Estimated

number of

deaths

Campylobacter jejuni or coli

2,500,000 200-730 55-70

1,375,000-

1,750,000 110-511

Clostridium perfringens 10,000 100 100 10,000 100

E. coli O157:H7 10,000-20,000 200-500 80 8,000-16,000 160-400

Listeria monocytogenes 1,795-1,860 445-510 85-95 1,526-1,767 378-485

Salmonella 800,000-4,000,000 800-4,000 87-96 696,000-3,840,000 696-3,840

Staphylococcus aureus 8,900,000 7,120 17 1,513,000 1,210

Toxoplasma gondii 4,111 82 50 2,056 41

Total 12,225,906-

15,435,971 8,947-13,042 Not applicable

3,605,582-

7,132,823 2,695-6,587

Source: Economic Research Service, USDA.

Table IV.2 presents cost-of-illness estimates for all foodborne illnesses and

illnesses from meat and poultry. Contaminated meat and poultry are

believed to be among the most common sources of foodborne illness from

these pathogens.

Page 29 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix IV 

Estimated Costs of Foodborne Illnesses

Table IV.2: “Cost-Of-Illness” Estimates

for Seven Major Pathogens From All

Foods and From Meat and Poultry

During 1993 All foods

Meat and poultry

Dollars in billions

Pathogens Estimated costs

Estimated

percentage

Estimated

costs

Campylobacter jejuni or

coli $0.6-1.0 75 $0.5-0.8

Clostridium perfringens 0.1 50 0.1

E. coli O157:H7 0.2-0.6 75 0.2-0.5

Listeria monocytogenes 0.2-0.3 50 0.1-0.2

Salmonella 0.6-3.5 50-75 0.3-2.6

Staphylococcus aureus 1.2 50 0.6

Toxoplasma gondii 2.7 100 2.7

Total $5.6-9.4 Not applicable $4.5-7.5

Source: Economic Research Service and Food Safety and Inspection Service, USDA.

ERS also used the willingness-to-pay method to estimate the value of

preventing deaths for five of the seven major pathogens. The results of this

analysis are shown in table IV.3.

Table IV.3: “Willingness-To-Pay”

Estimate for Five Major Pathogens in

1992

Dollars in billions

Pathogens

Estimated number of

deaths from

foodborne sources

Implied value of

preventing deaths

Salmonella 960-1,920 $3.8-13.4

Campylobacter jejuni or coli 120-360 .48-2.5

E. coli O157:H7 146-389 .58-2.7

Listeria monocytogenes 378-433 1.5-3.0

Toxoplasma gondii 42 .17-.29

Total 1,646-3,144 $6.6-22.0

Source: Economic Research Service, USDA.

Page 30 GAO/RCED-96-96 Information of Foodborne Illnesses
Appendix V 

Major Contributors to This Report

Edward M. Zadjura, Assistant Director

Jay Cherlow, Assistant Director for Economic Analysis

Daniel F. Alspaugh, Project Leader

Carol Herrnstadt Shulman

Jonathan M. Silverman

(150639) Page 31 GAO/RCED-96-96 Information of Foodborne Illnesses
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