Consumption of unpasteurised milk in the United States has presented a public health challenge for decades because of the increased risk of pathogen transmission causing illness outbreaks. We analysed Foodborne Disease Outbreak Surveillance System data to characterise unpasteurised milk outbreaks. Using Poisson and negative binomial regression, we compared the number of outbreaks and outbreak-associated illnesses between jurisdictions grouped by legal status of unpasteurised milk sale based on a May 2019 survey of state laws. During 2013-2018, 75 outbreaks with 675 illnesses occurred that were linked to unpasteurised milk; of these, 325 illnesses (48%) were among people aged 0-19 years. Of 74 single-state outbreaks, 58 (78%) occurred in states where the sale of unpasteurised milk was expressly allowed. Compared with jurisdictions where retail sales were prohibited (n = 24), those where sales were expressly allowed (n = 27) were estimated to have 3.2 (95% CI 1.4-7.6) times greater number of outbreaks; of these, jurisdictions where sale was allowed in retail stores (n = 14) had 3.6 (95% CI 1.3-9.6) times greater number of outbreaks compared with those where sale was allowed on-farm only (n = 13). This study supports findings of previously published reports indicating that state laws resulting in increased availability of unpasteurised milk are associated with more outbreak-associated illnesses and outbreaks.

Foodborne illness is common in the United States with most, but not all, foodborne pathogens causing symptoms of acute gastroenteritis (AGI). Outpatient care is the most frequent type of medical care sought; however, more accurate estimates of outpatient costs are needed to inform food safety policy decision. Using the U.S. MarketScan Commercial Claims and Encounters database, we quantified the per-visit cost of outpatient visits with any AGI-related diagnosis (including pathogen-specific and nonspecific or symptom-based diagnoses) and for those with a pathogen-specific diagnosis for 1 of 29 pathogens commonly transmitted through food (including pathogens that cause AGI and some that do not). Our estimates included the per-case cost of office visits and associated laboratory tests and procedures as well as the conservative estimates of prescription cost. Most AGI outpatient visits were coded using nonspecific codes (e.g., infectious gastroenteritis), rather than pathogen-specific codes (e.g., Salmonella). From 2012 to 2015, we identified more than 3.4 million initial outpatient visits with any AGI diagnosis and 45,077 with a foodborne pathogen-specific diagnosis. As is typical of treatment cost data, severe cases of illness drove mean costs above median. The mean cost of an outpatient visit with any AGI was $696 compared with the median of $162. The mean costs of visits with pathogen-specific diagnoses ranged from $254 (median $131; interquartile range [IQR]: $98-184) for Streptococcus spp. Group A (n=22,059) to $1761 (median $161; IQR: $104-$1101) for Clostridium perfringens (n=30). Visits with two of the most common causes of foodborne illness, nontyphoidal Salmonella and norovirus, listed as a diagnosis, had mean costs of $841 and $509, respectively. Overall, the median per-case costs of outpatient visits increased with age, with some variation by pathogen. More empirically based estimates of outpatient costs for AGI and specific pathogens can enhance estimates of the economic cost of foodborne illness used to guide food policy and focus prevention efforts.

Quantifying the effect of public health actions on population health is essential when justifying sustained public health investment. Using modeling, we conservatively estimated that rapid response to a multistate foodborne outbreak of Salmonella Typhimurium in the United States in 2018 potentially averted 94 reported cases and $633,181 in medical costs and productivity losses.

We conservatively estimated the US economic burden of fungal diseases as $11.5 billion in 2019: direct medical costs ($7.5 billion), productivity loss due to absenteeism ($870 million), and premature deaths ($3.2 billion). An alternative "value of statistical life" approach yielded >$48 billion. These are likely underestimates given underdiagnosis and underreporting.

Novel outbreak-associated food vehicles (i.e., foods not implicated in past outbreaks) can emerge as a result of evolving pathogens and changing consumption trends. To identify these foods, we examined data from the Centers for Disease Control and Prevention Foodborne Disease Outbreak Surveillance System and found 14,216 reported outbreaks with information on implicated foods. We compared foods implicated in outbreaks during 2007-2016 with those implicated in outbreaks during 1973-2006. We identified 28 novel food vehicles, of which the most common types were fish, nuts, fruits, and vegetables; one third were imported. Compared with other outbreaks, those associated with novel food vehicles were more likely to involve illnesses in multiple states and food recalls and were larger in terms of cases, hospitalizations, and deaths. Two thirds of novel foods did not require cooking after purchase. Prevention efforts targeting novel foods cannot rely solely on consumer education but require industry preventive measures.

Objectives. Health utility estimates from the current era of HIV treatment, critical for cost-effectiveness analyses (CEA) informing HIV health policy, are limited. We examined peer-reviewed literature to assess the appropriateness of commonly referenced utilities, present previously unreported quality-of-life data from two studies, and discuss future implications for HIV-related CEA. Methods. We searched a database of cost-effectiveness analyses specific to HIV prevention efforts from 1999 to 2016 to identify the most commonly referenced sources for health utilities and to examine practices around using and reporting health utility data. Additionally, we present new utility estimates from the Centers of Disease Control and Prevention's Medical Monitoring Project (MMP) and the INSIGHT Strategies for Management of Anti-Retroviral Therapy (SMART) trial. We compare data collection time frames, sample characteristics, assessment methods, and key estimates. Results. Data collection for the most frequently cited utility estimates ranged from 1985 to 1997, predating modern HIV treatment. Reporting practices around utility weights are poor and lack details on participant characteristics, which may be important stratifying factors for CEA. More recent utility estimates derived from MMP and SMART were similar across CD4+ count strata and had a narrower range than pre-antiretroviral therapy (ART) utilities. Conclusions. Despite the widespread use of ART, cost-effectiveness analysis of HIV prevention interventions frequently apply pre-ART health utility weights. Use of utility weights reflecting the current state of the US epidemic are needed to best inform HIV research and public policy decisions. Improved practices around the selection, application, and reporting of health utility data used in HIV prevention CEA are needed to improve transparency.

Cost-effectiveness analysis (CEA), as noted by the Second Panel on Cost Effectiveness in Health and Medicine (herein, the Second Panel), “provides a framework for comparing the relative value of different interventions, along with information that can help decision makers sort through alternatives and decide which ones best serve their programmatic and financial needs.”1 The CEA, as well as other methods of economic evaluation, such as budgetary impact analysis and cost–benefit analysis, can inform health policy decisions. In 1996, the first Panel on Cost Effectiveness in Health and Medicine (herein, the First Panel) issued recommendations intended to improve the quality and comparability of CEA studies.2 The Second Panel has provided updated recommendations on the conduct, documentation, and reporting of CEAs with the same general intent.3

Using National HIV Behavioral Surveillance (NHBS) cross-sectional survey and HIV testing data in 21 U.S. metropolitan areas, we identify sex practices among sexually active men who have sex with men (MSM) associated with: (1) awareness of HIV status, and (2) engagement in the HIV care continuum. Data from 2008, 2011, and 2014 were aggregated, yielding a sample of 5079 sexually active MSM living with HIV (MLWH). Participants were classified into HIV status categories: (1) unaware; (2) aware and out of care; (3) aware and in care without antiretroviral therapy (ART); and (4) aware and on ART. Analyses were conducted examining sex practices (e.g. condomless sex, discordant condomless sex, and number of sex partners) by HIV status. Approximately 30, 5, 10 and 55% of the sample was classified as unaware, aware and out of care, aware and in care without ART, and aware and on ART, respectively. Unaware MLWH were more likely to report condomless anal sex with a last male partner of discordant or unknown HIV status (25.9%) than aware MLWH (18.0%, p value < 0.0001). Unaware MLWH were 3 times as likely to report a female sex partner in the prior 12 months as aware MLWH (17.3 and 5.6%, p-value < 0.0001). When examining trends across the continuum of care, reports of any condomless anal sex with a male partner in the past year (ranging from 65.0 to 70.0%), condomless anal sex with a male partner of discordant or unknown HIV status (ranging from 17.7 to 21.3%), and median number of both male and female sex partners were similar. In conclusion, awareness of HIV and engagement in care was not consistently associated with protective sex practices, highlighting the need for continued prevention efforts.

An estimated 1.2 million people aged 13 years and older are living with human immunodeficiency virus (HIV) infection in the United States1, and approximately 45,000 people are newly diagnosed with the virus each year.2 Over the last 30 years, condom use has been a key element of comprehensive approaches to HIV prevention.3–9 For instance, the National HIV/AIDS Strategy for the United States 2010 (updated in 2015) calls for promotion of condom use in combination with other prevention approaches.10 Condom distribution campaigns, a frequently used public health intervention, make condoms freely available in settings frequented by people believed to be at high risk of transmitting or acquiring HIV. However, data regarding the effectiveness of condom distribution campaigns remain limited due to several methodological challenges. Knowledge of the strength of evidence of condom distribution campaign effectiveness is important for priority setting and the efficient allocation of HIV prevention resources among competing interventions.11–13 This paper examines limitations in the literature regarding condom distribution campaigns and the difficulties in estimating the effectiveness of campaigns through observational studies and mathematical modeling.