Reference no: EM133569995

Introduction

On June 2, 2008, the Centers for Disease Control and Prevention (CDC) announced its investigation of an ongoing multistate outbreak of human Salmonella serotype Saintpaul infections. CDC identified the consumption of raw tomatoes as the likely source of the illnesses in at least two states and a public advisory was issued (CDC, 2008). By the time the outbreak was officially declared over on August 28, 2008, 1,442 people had been reported infected, at least 286 people had been hospitalized, and the infection might have contributed to 2 deaths.

Despite the early identification of tomatoes as a potential pathogen source, jalapeno peppers were subsequently identified as the major source, with some implication of serrano peppers as well (Behravesh et al., 2011; Jungk et al., 2008). Was the public advisory to avoid raw tomatoes issued too early in the outbreak investigation, despite its intent as a control measure? Some, including the Florida Tomato Committee, may believe so, considering the outcome of the investigation: the estimated economic cost to the tomato industry was more than $600 million in Florida and close to $100 million in Georgia (Beach, 2013).

This outbreak is one of many examples that could be used to illustrate the difficulties in determining when to go public with food safety information about potential public health risks. In a 1999 news article about a Listeria monocytogenes outbreak, CDC foodborne illness epidemiologist Paul Mead summed up the conundrum that health officials face when reviewing preliminary data during an outbreak investigation: "Food safety recalls are always either too early or too late. If you're right, it's always too late. If you're wrong, it's always too early." Go public too early, and make a mistake, and a corporation or industry's reputation could unduly suffer. Go public too late, and individuals and businesses can be denied critical information they could use to protect public health.

Contributing to the difficulties is the lack of guidelines for health officials and the food industry on when to go public with risk information. Providing timely information is good risk communication practice. How to determine what is timely is often unclear. Each investigation is unique, nonlinear, and dynamic--and can involve a number of different organizations and various government departments (Health Canada, 2011). Communication with the public about risks, however, plays an important role in disease prevention (Liang & Scammon, 2011).

In 2012, the U.S. Government Accountability Office (GAO) identified weaknesses in the Food and Drug Administration's (FDA) food advisory and recall process. According to the GAO report, FDA officials indicated that they use professional experience to look for a tipping point, defined as the time when evidence collected is sufficient to allow the agency to provide consumers with information that will help them avoid unsafe food (GAO, 2012). Without predetermined guidelines, determining the right time to provide the public with information becomes a subjective, rather than an objective, decision.

FDA is not alone in its lack of clarity on when to go public with food risk information. Dr. David Williams, Ontario's chief medical officer of health during the time of a 2008 Listeria monocytogenes outbreak linked to Maple Leaf deli meats, stated that to wait until one has evidence beyond doubt "is often too late to protect the public." Dr. David McKeown, Toronto's public health medical officer during that time, remarked that the Canadian Food Inspection Agency often waits for conclusive evidence that a specific product is responsible for documented human illness before taking action (Parliament of Canada, 2009).

The intent of this special report is to contribute to the discourse on public risk communication related to foodborne hazards, and to argue for the establishment of guidelines for determining what is timely, the information content of going-public messages, and to aid public health entities in protecting consumers' health.

Role of Risk Communication in Mitigating Foodborne Illness

Risk communication is an integral component of risk governance. Risk governance is based on principles of cooperation, participation, mitigation, and sustainability--and demands an approach that is guided by resilience, as well as knowledge management and exchange (Sellke & Renn, 2010). Information provision on its own is not enough. Risk communication should provide individuals with all the insights they need in order to make decisions or judgments that reflect the best available knowledge and their own preferences (Renn, 2009).

Communicators should explain what the responsible institutions and other relevant food chain actors are doing to identify, prevent, and mitigate food-related risks, as well as provide information on what self-protection strategies consumers can undertake (Cope et al., 2010). A national consumer survey conducted by Hallman and colleagues (2009) demonstrated that while the public values recall information, much of what is presented is either confusing (resulting in incorrect actions) or not heeded (because of optimistic bias).

To support consumer decision making, available information must support what consumers want and need to know, which might or might not be what information authorities want to relay (Harro-Loit, Vihalemm, & Ugur, 2012). Using a combination of qualitative and quantitative methods, Cope and coauthors (2010) suggest experts perceived consumers as unable to conceptualize implications of risk and uncertainties of risk assessment, while the consumers' perception was that institutions with responsibility for consumer protection deliberately masked the uncertainty associated with risk in order to protect vested and economic interests.

Trust is a key tenet of risk communication. Organizations can use open, transparent information and dialogue to build and sustain public trust. Communication begins even before a single word is said; the very willingness to engage in dialogue can set a foundation for building trust (Fischhoff, 1995). Yet public trust can be undermined by failures in the public's belief in the competence and knowledge of authorities, their fairness and honesty, and their ability to communicate scientific information in a meaningful way (Abraham, 2011; Renn, 2009). Vos and coauthors (2011) noted that authorities often keep silent about a risk in an attempt to avoid raising public concern and generating panic. Accurate, extensive, and timely information is more likely to reduce anxiety, however, and to activate people in self-efficacy and protective measures. Funk and coauthors (2009) have shown that disease transmission risk management decisions are dependent on the quality of the information available and that the tendency to act is reduced with decreasing quality of information. The literature indicates that trust, timeliness, and the quality of information provided when going public are all factors in a consumer's likelihood to act.

Defining Timely

The literature on what timely communication means or how it is measured is vague. The U.S. Department of Health and Human Services (HHS), the principal agency for protecting the health of people in the U.S., reported that it "values the free exchange of ideas, data, and information, and doing so in a manner that is timely, responsive, and accurate" (HHS, 2017). The risk communication guidelines published by the European Food Safety Authority (EFSA) defined timely communication as "published as soon as practical" with respect to the release of risk assessment and related communications that may inform public decision making (EFSA, 2012). Other descriptions of timely communications have incorporated a sense of urgency in their descriptions. For example, FDA's guidelines for industry call for the prompt issue of a press release in a situation where the product could pose a significant health hazard and the recalled product is in the hands of consumers (FDA, 2003).

Likewise, CDC has recognized that people want information immediately at the onset of a crisis. In 2002, CDC developed and adopted the integrative model of crisis and emergency risk communication (CERC). CERC provides six guiding principles for institutions or groups with official crisis response roles: be first, be right, be credible, express empathy, promote action, and show respect. The first of these--be first--acknowledges the importance of communicating information quickly; for the public, the first source of information often becomes the preferred source (CDC, 2016). This guiding principle of be first is not as explicit, however, as the response timelines of the U.S. Federal Emergency Management Agency (FEMA) that target the provision of response-level operational communications in high-risk urban areas within 1 hour of an incident (FEMA, 2012). Every outbreak and incident is unique, and any guidelines used to determine when to go public should be sufficiently flexible to adapt risk communications protocols on a case-by-case basis, while still providing sufficient structure to allow objective evaluation. Chess and coauthors (1988) argued that the early release of information sets the pace for resolution of the problem, protects an organization and authorities against loss of credibility and trust, allows for better control of the accuracy of information, and provides people with information that affects their lives. They cautioned that communities find it difficult to accept any justification for withholding information when health risks are involved, regardless of the risks. Generic guidelines for the release of information were suggested (Table 1).

Arguments Against Timely Disclosure of Risks

Protecting the Public From Information Overload

In March 2009, The Globe and Mail newspaper reported on an investigation by the Polaris Institute into bottled water use in Canada and the number of recalls of the product that had been issued by the Canadian government. Of the 49 recalled products, the Polaris Institute was only able to find public warnings issued for seven of the recalls. Garfield Balsom, a food safety and recall specialist at the Canadian Food Inspection Agency, stated that there are no hard-and-fast rules on what requires public notification (Mittelstaedt, 2009).

There is no indication in the literature that consumers benefit from paternalistic protection decisions to guard against information overload. Good risk communication practice is to be open and transparent; withholding information, for whatever seemingly logical reason, denies consumers the opportunity to take measures to protect their health. The information might eventually leak out anyway, thereby undermining an organization's credibility (Chess, Hance, & Sandman, 1988).

Unintended Consequences

On June 12, 1996, the Ministry of Health in Ontario, Canada, issued a public health advisory on the presumed link between consumption of California strawberries and an outbreak of diarrheal illness among some 40 people in the metropolitan Toronto area. The announcement followed a similar statement from the Department of Health and Human Services in Houston, Texas, which was investigating a cluster of 18 cases of Cyclospora illness among oil executives. By choosing to go public about a presumptive source during the early stages of the outbreak investigation, health officials took a proactive measure in the interest of public health. Two outcomes were possible: if it turned out that strawberries were implicated, the ministry made a smart decision, warning people against something that could hurt them. If the strawberries were not implicated, then the ministry made a bad decision, with the result that strawberry growers and sellers lost money and people stopped eating something that was good for them. By the end of August 1996, 1,465 cases of cyclosporiasis had been reported in North America, and traceback investigations had identified Guatemalan raspberries as the source of the pathogen (Manuel et al., 2000; Powell, 2011).

The limited research that has been carried out to assess the impacts of proactive measures to deal with defective products has yielded mixed results. Siomkos (1999) reported that consumers appreciate the recall of an unsafe product if the recall is decided spontaneously by the company and not imposed by national authorities. Companies that go further, taking aggressive action to recall the harmful product immediately--informing customers about what to do with the harmful product and being in constant contact with them--will rapidly recapture lost business (market) share. Claeys and coauthor (2012) called this form of proactive self-disclosure of a crisis "stealing thunder," and found that it can be effective in minimizing crisis damage and maintaining the organization's credibility.

Conversely, Chen and coauthors (2009) determined that, regardless of the company or product characteristics, proactive recall strategies had a more negative effect on company value than more passive recall strategies because stock markets interpret a proactive strategy as a signal that the potential harm from the defective product is severe. Ulmer and coauthor (2000) demonstrated that the strategic ambiguity employed by Jack in the Box's corporate leaders in their crisis communications during their 1993 E. coli outbreak benefited their financial stakeholders over other audiences.

Consumer Misinterpretation or Lack of Understanding

Successful risk communication occurs when there is mutual learning, where the gap in knowledge between the information sender and receiver is minimal (Shaw, Takeuchi, Matsuura, & Saito, 2012). The information receiver uses common sense mechanisms to process the information and draw inferences, which is important for establishing risk perceptions (Renn, 2009). According to Andrews (2011), misconceptions about the public's lack of interest or understanding of warnings and disclosures are common. If efforts are made, however, to accommodate audience characteristics, prior beliefs, message content, and proper delivery modes, warnings and disclosures can be effective communication tools and remedies for consumer and public health policy (Andrews, 2011).

Simply providing the data on potential risks is never enough. Putting out numerical or scientific information without appropriately framing the message and providing adequate explanation often leads to public confusion. Lofstedt and coauthors (2012) provided the example of medical data released through the FDA Adverse Event Reporting System (FAERS). FAERS is a database that contains information on adverse event and medication error reports submitted to FDA. As a database, FAERS is designed to simply offer data. As a consequence, more than 25% of U.S. adults surveyed by the researchers indicated that they would stop taking their medication outright if it were posted on FAERS, and almost half would not know what to do. Lofstedt and coauthors (2012) advocated for the incorporation of sound risk communication strategies by FDA into its transparency efforts in order to communicate risks properly.

The Challenge of New Media

The Internet has erased the formal distinction between communicator and audience; there has been a shift in the balance of power related to voice. In traditional media, government or industry had greater control over how their message was prepared and conveyed, and who received it. Blogs and other platforms that support user-generated content such as YouTube, Facebook, and Twitter have created a conversation space where anyone can participate and the distinction between expert and layperson is erased (Abraham, 2011; Reynolds, 2011).

Effective communication about risks remains important; the advent of the Internet and new media simply shorten timelines dramatically. Kasperson and coauthors (1988) first formalized the theory of the social amplification of risk, which helped explain why minor technical risks become major public risks. New media accelerates the speed at which this shift can take place. Organizations that are not nimble in sharing information will lose their place in the dialogue and may be usurped by others who do not have the public's best interest in mind (Reynolds, 2011).

Examples/Case Studies

In 2008, an investigation of a cluster of E. coli O157:H7 infections in California pointed to a single restaurant as the source (Marler, 2012a). The investigation led to linked illnesses in other states, causing investigators to suspect a common contaminated ingredient. Later, the same strain was found in an outbreak in Canada, where a traceback investigation led to lettuce as the source, which had also been supplied to the unnamed restaurants in California. Dr. Robert Tauxe, CDCs deputy director of the Division of Foodborne, Waterborne, and Environmental Diseases, defended the practice of not naming a company's identity, saying it protects the public's health and the businesses that could be hurt by bad publicity (Marler, 2012b; Powell, 2012). He argued that "the longstanding policy is we publicly identify a company only when people can use that information to take specific action to protect their health. On the other hand, if there's not an important public health reason to use the name publicly, CDC doesn't use the name publicly" (Marler, 2012b; Powell, 2012). It is not clear, however, what standards are considered to determine what is defined as an "important public health reason," and why some identities are revealed and some are not. Tauxe acknowledged the lack of written policy and said it's a "case-by-case thing" (Marler, 2012b; Powell, 2012).

An E. coli outbreak investigation involving romaine lettuce in 2011 also failed to disclose the identity of the responsible grower and distributors (Beach, 2012). FDA press officer Sebastian Cianci acknowledged they knew the farm from where the lettuce originated but didn't want to implicate a specific member in the supply chain when they weren't sure at what point the produce was contaminated (Beach, 2012). Many of the affected people reported eating from Schnucks salad bars, leading Schnucks stores to voluntarily pull romaine lettuce from their salad bars (PRWeb, 2012). By the end of the year Schnucks acknowledged they were "Chain A" mentioned in CDC reports, but they refused to name their lettuce supplier. The final CDC report issued in 2012, however, updated the number of cases and repeated previous statements, but still did not name the company involved (CDC, 2012; PRWeb, 2012).

In May 2012, the South Carolina Department of Health and Environmental Control (DHEC) refused to name a restaurant linked to an ongoing E. coli outbreak. Even though they sent an advisory regarding the outbreak to physicians, they did not alert the public ("DHEC Had No Business," 2012). People used social media to demonstrate their frustration and demanded to know the name of the restaurant, posting statements such as, "I smell some hush hush money so the name doesn't get in the public! Like others, I love Mexican food but not at the risk of my health. And if it's so safe, why not release the name? Other Mexican restaurants may suffer loss of business because of this, including this restaurant!" (Chapman, 2012). After approximately a week, the name of the restaurant was released, only after the El Mexicano restaurant allowed the agency to release its name, raising questions as to the priorities of DHEC ("DHEC Had No Business," 2012). DHEC assured the public that the restaurant was safe to eat at once again.

Evensen and coauthors (2012) documented an example of candor and openness in information provision that shifted public perception of the risk in question towards an improved understanding of the risk and its potential impact on human health. The authors described local residents' anxiety about the sudden deaths of nearly 3,000 birds and countless fish in Sleeping Bear Dunes National Lakeshore, Michigan, in 2006. People's anxiety was eased by scientists sharing their knowledge about type E botulism in wildlife. The public's concerns were addressed by information through multiple methods, including local newspaper coverage and public presentations by local experts. Communication by officials was immediate and direct, which helped to maintain public trust. Members of the public cited increased knowledge about botulism, its causes, and its effects, which helped to shift their concerns away from human and pet health toward an understanding of botulism in wildlife and the effect on environmental well-being.

Conclusion: A Blueprint for When to Go Public and What to Say

If foodborne outbreaks are not being publicly disclosed, or are not disclosed in a timely manner, how will people become aware that there are problems? Communication about foodborne risks allows the public to make informed decisions about what they choose to eat. Acquiring risk knowledge also allows the public to build risk literacy--the ability to access, analyze, evaluate, and recommunicate information--that can facilitate efficient public risk communication when a crisis arises (Harro-Loit et al., 2012).

Public health officials have a challenging job: it can be difficult to discern true signals about an emerging risk from random noise. But establishing some ground rules--and publicizing those rules--would help build public trust. Past risk communication research has demonstrated that if people have confidence in the decision-making process, they will have more confidence in the decision. People might not agree about when to go public, but if the assumptions are laid on the table, and value judgments are acknowledged, then maybe the focus can be on fewer sick people.

Choo (2009) suggests that, in theory, a rational decision threshold could be set based on threat probability and a cost-benefit analysis of false alarms and actual occurrence. In practice, however, economic, political, and social forces--as well as by individuals, groups, and institutions that act according to their beliefs, values, and interests--influence when to go public.

We propose that communicators and public health organizations develop guidelines for public disclosure of risks based on the questions in Table 2. Clear, accurate, and timely communication with the public is an important public health function, and such communication becomes especially critical during public health emergencies. Communication is important for educating the public about steps that individuals can take to reduce the spread of infectious disease and to protect themselves.

Not naming the source of an outbreak or giving recall information too late affects the public's trust in agencies. Furthermore, when the agencies themselves do not have a standard procedure regarding when to name or not name implicated firms in an outbreak, it seems as though the agencies' priority is the firm and not public health.

Task:

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