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Quantifying Human Health Risks from Virginiamycin Used in Chickens

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  • Louis A. Cox
  • Douglas A. Popken

Abstract

The streptogramin antimicrobial combination Quinupristin‐Dalfopristin (QD) has been used in the United States since late 1999 to treat patients with vancomycin‐resistant Enterococcus faecium (VREF) infections. Another streptogramin, virginiamycin (VM), is used as a growth promoter and therapeutic agent in farm animals in the United States and other countries. Many chickens test positive for QD‐resistant E. faecium, raising concern that VM use in chickens might compromise QD effectiveness against VREF infections by promoting development of QD‐resistant strains that can be transferred to human patients. Despite the potential importance of this threat to human health, quantifying the risk via traditional farm‐to‐fork modeling has proved extremely difficult. Enough key data (mainly on microbial loads at each stage) are lacking so that such modeling amounts to little more than choosing a set of assumptions to determine the answer. Yet, regulators cannot keep waiting for more data. Patients prescribed QD are typically severely ill, immunocompromised people for whom other treatment options have not readily been available. Thus, there is a pressing need for sound risk assessment methods to inform risk management decisions for VM/QD using currently available data. This article takes a new approach to the QD‐VM risk modeling challenge. Recognizing that the usual farm‐to‐fork (“forward chaining”) approach commonly used in antimicrobial risk assessment for food animals is unlikely to produce reliable results soon enough to be useful, we instead draw on ideas from traditional fault tree analysis (“backward chaining”) to reverse the farm‐to‐fork process and start with readily available human data on VREF case loads and QD resistance rates. Combining these data with recent genogroup frequency data for humans, chickens, and other sources (Willems et al., 2000, 2001) allows us to quantify potential human health risks from VM in chickens in both the United States and Australia, two countries where regulatory action for VM is being considered. We present a risk simulation model, thoroughly grounded in data, that incorporates recent nosocomial transmission and genetic typing data. The model is used to estimate human QD treatment failures over the next five years with and without continued VM use in chickens. The quantitative estimates and probability distributions were implemented in a Monte Carlo simulation model for a five‐year horizon beginning in the first quarter of 2002. In Australia, a Q1‐2002 ban of virginiamycin would likely reduce average attributable treatment failures by 0.35 × 10−3 cases, expected mortalities by 5.8 × 10−5 deaths, and life years lost by 1.3 × 10−3 for the entire population over five years. In the United States, where the number of cases of VRE is much higher, a 1Q‐2002 ban on VM is predicted to reduce average attributable treatment failures by 1.8 cases in the entire population over five years; expected mortalities by 0.29 cases; and life years lost by 6.3 over a five‐year period. The model shows that the theoretical statistical human health benefits of a VM ban range from zero to less than one statistical life saved in both Australia and the United States over the next five years and are rapidly decreasing. Sensitivity analyses indicate that this conclusion is robust to key data gaps and uncertainties, e.g., about the extent of resistance transfer from chickens to people.

Suggested Citation

  • Louis A. Cox & Douglas A. Popken, 2004. "Quantifying Human Health Risks from Virginiamycin Used in Chickens," Risk Analysis, John Wiley & Sons, vol. 24(1), pages 271-288, February.
  • Handle: RePEc:wly:riskan:v:24:y:2004:i:1:p:271-288
    DOI: 10.1111/j.0272-4332.2004.00428.x
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    2. Harry M. Marks & Margaret E. Coleman & C.‐T. Jordan Lin & Tanya Roberts, 1998. "Topics in Microbial Risk Assessment: Dynamic Flow Tree Process," Risk Analysis, John Wiley & Sons, vol. 18(3), pages 309-328, June.
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    Cited by:

    1. I. Forrester & J. C. Hanekamp1, 2006. "Precaution, Science and Jurisprudence: a Test Case," Journal of Risk Research, Taylor & Francis Journals, vol. 9(4), pages 297-311, June.
    2. H. Scott Hurd & Sasidhar Malladi, 2008. "A Stochastic Assessment of the Public Health Risks of the Use of Macrolide Antibiotics in Food Animals," Risk Analysis, John Wiley & Sons, vol. 28(3), pages 695-710, June.
    3. Louis Anthony (Tony) Cox, Jr & Douglas A. Popken, 2008. "Overcoming Confirmation Bias in Causal Attribution: A Case Study of Antibiotic Resistance Risks," Risk Analysis, John Wiley & Sons, vol. 28(5), pages 1155-1172, October.
    4. Louis Anthony (Tony) Cox & Djangir Babayev & William Huber, 2005. "Some Limitations of Qualitative Risk Rating Systems," Risk Analysis, John Wiley & Sons, vol. 25(3), pages 651-662, June.
    5. Louis Anthony (Tony) Cox, Jr. & Douglas A. Popken & Jeremy J. Mathers, 2009. "Human Health Risk Assessment of Penicillin/Aminopenicillin Resistance in Enterococci Due to Penicillin Use in Food Animals," Risk Analysis, John Wiley & Sons, vol. 29(6), pages 796-805, June.
    6. H. Gregg Claycamp, 2006. "Rapid Benefit‐Risk Assessments: No Escape from Expert Judgments in Risk Management," Risk Analysis, John Wiley & Sons, vol. 26(1), pages 147-156, February.
    7. Louis Anthony Cox & Douglas A. Popken, 2004. "Bayesian Monte Carlo Uncertainty Analysis of Human Health Risks from Animal Antimicrobial Use in a Dynamic Model of Emerging Resistance," Risk Analysis, John Wiley & Sons, vol. 24(5), pages 1153-1164, October.
    8. Louis Anthony (Tony) Cox & Douglas A. Popken & Richard Carnevale, 2007. "Quantifying Human Health Risks from Animal Antimicrobials," Interfaces, INFORMS, vol. 37(1), pages 22-38, February.
    9. Bethany Cooper & Walter O. Okello, 2021. "An economic lens to understanding antimicrobial resistance: disruptive cases to livestock and wastewater management in Australia," Australian Journal of Agricultural and Resource Economics, Australian Agricultural and Resource Economics Society, vol. 65(4), pages 900-917, October.
    10. Louis Anthony (Tony) Cox Jr & Douglas A. Popken, 2010. "Assessing Potential Human Health Hazards and Benefits from Subtherapeutic Antibiotics in the United States: Tetracyclines as a Case Study," Risk Analysis, John Wiley & Sons, vol. 30(3), pages 432-457, March.
    11. Louis Anthony Cox & Douglas A. Popken & Jian Sun & Xiao‐ping Liao & Liang‐Xing Fang, 2020. "Quantifying Human Health Risks from Virginiamycin Use in Food Animals in China," Risk Analysis, John Wiley & Sons, vol. 40(6), pages 1244-1257, June.
    12. Louis Anthony (Tony) Cox & Douglas A. Popken, 2006. "Quantifying Potential Human Health Impacts of Animal Antibiotic Use: Enrofloxacin and Macrolides in Chickens," Risk Analysis, John Wiley & Sons, vol. 26(1), pages 135-146, February.
    13. Louis Anthony Cox, 2006. "Animal Antibiotic Use and Human Health: No Expert Judgment is Needed to Determine that Reducing Cases Reduces Risk," Risk Analysis, John Wiley & Sons, vol. 26(1), pages 157-161, February.

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