Globally, billions of people are at risk of foodborne diseases (FBDs) and millions
fall ill from these every year. Many die as a result of consuming unsafe food. FBDs
can also affect economic development through the tourism, agricultural and
food export industries. The South-East Asia Region has the second highest
burden of FBDs after the African Region, with more than 150 million cases and
175 000 deaths annually.
The World Health Organization has launched a comprehensive and first of
its kind report to estimate the global and regional burden of FBDs. This report will
support policy-makers in implementing the right strategies to prevent, detect and
manage foodborne risks to improve food safety. It highlights the work of WHO's
Regional Office for South-East Asia with national governments on improving
surveillance of foodborne diseases and meeting unique local challenges.
Burden of
foodborne diseases
in the South-East Asia Region
ISBN 978-92-9022-503-4
World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
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Burden of foodborne diseases
in the South-East Asia Region
WHO Library Cataloguing-in-Publication data
World Health Organization, Regional Office for South-East Asia.
Burden of foodborne diseases in the South-East Asia Region.
1. Foodborne Diseases 2. Epidemiology 3. Food contamination ISBN
978-92-9022-503-4
(NLM classification: WC 268)
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Printed in India
Contents
Acronyms................................................................................................................ v
Introduction: Foodborne diseases ...........................................................................1
Foodborne infections...................................................................................................2
Chemicals and toxins in food.......................................................................................3
Food allergy ................................................................................................................4
Global burden of foodborne diseases ......................................................................5
Objectives...................................................................................................................5
Methodology...............................................................................................................6
Gaps and limitations....................................................................................................9
Foodborne diseases in the WHO South-East Asia Region.......................................11
Foodborne diseases in under-five children.................................................................13
Conclusions and action points................................................................................17
Annexes
1.
Classification of foodborne diseases...............................................................21
2
A guide to national burden of foodborne disease study..................................42
3
Categorization of subgroups under WHO regions..........................................47
Burden of foodborne diseases in the South-East Asia Region
iii
Acronyms
CA
Codex Alimentarius
DALY
disability-adjusted life-year
ETECenterotoxigenic Escherichia coli
EPECenteropathogenic Escherichia coli
FAO
Food and Agriculture Organization of the United Nations
FBDs
foodborne diseases
FERG
Foodborne Disease Burden Epidemiology Reference Group
GEMS
Global Environmental Monitoring System
HAV
hepatitis A virus
IHR (2005)
International Health Regulations (2005)
INFOSAN
International Food Safety Authorities Network
NTSnon-typhoidal Salmonella enterica
POPs
persistent organic pollutants
sp., spp.
species (sing. and plural)
WHO
World Health Organization
Burden of foodborne diseases in the South-East Asia Region
v
Introduction: Foodborne diseases
Food is an essential requirement for humans but it can also be a vehicle of disease
transmission if contaminated with harmful microbes (bacteria, viruses or parasites) or
chemicals/toxins. Globally, billions of people are at risk of foodborne diseases (FBDs)
and millions fall ill every year. Many also die as a result of consuming unsafe food.
Foodborne illnesses are mainly caused due to food contamination with harmful
bacteria, viruses, parasites, toxins or chemicals. Microbial and chemical risks could
be introduced at the farm level (e.g. using water contaminated by industrial waste
or poultry farm waste for irrigation of crops). Similarly, such risks may emerge during
processing, transportation or storage of food and food products.
While many FBDs may be self-limiting, some can be very serious and even result
in death. These diseases may be more serious in children, pregnant women and those
who are older or have a weakened immune system. Children who survive some of
the more serious FBDs may suffer from delayed physical and mental development,
impacting their quality of life permanently. Food allergy is another emerging problem.
A brief description of major FBDs of public health importance is presented in Annex 1.
FBDs are more critical in developing countries due to various reasons, such as use
of unsafe water for cleaning and processing of food, poor food production processes
and food handling, absence of adequate food storage infrastructure, and inadequate
or poorly enforced regulatory standards. The tropical climate in many countries in the
Region also favours the proliferation of pests and naturally occurring toxins and increase
the risk of contracting parasitic diseases including worm infestations.
FBDs can also affect economic development through the tourism, agriculture
and food export industries. In a globalized world, FBDs do not recognize borders. A
local incident can quickly become an international emergency due to the speed and
range of product distribution, impacting health, international relations and trade. A
brief description of foodborne diseases is presented in Annex 1.
Burden of foodborne diseases in the South-East Asia Region
1
Foodborne infections
When certain disease-causing microbes (bacteria, viruses or parasites) contaminate
food, they can cause foodborne illness, often called “food poisoning”. Foods that are
contaminated may not look, taste or smell any different from foods that are safe to eat.
Salmonella, Campylobacter, Shigella and Escherichia coli (also called E. coli) are the
common bacteria that cause foodborne illnesses. Salmonella is the most common cause
of foodborne illnesses and meat, egg and seafood are common food sources for much
illnesses. Some foodborne bacteria like Listeria monocytogenes can even grow inside
the refrigerator in ready-to-eat food. Staphylococcus aureus bacteria grow in food and
produce toxins that cause staphylococcal food poisoning. Viruses that commonly cause
foodborne illnesses are norovirus and hepatitis A virus (HAV), which can be transmitted
through contaminated water as well as contaminated surfaces.
Foodborne bacteria are often naturally present in food and under the right
conditions, a single bacterium can grow into millions of bacteria in a few hours. These
bacteria multiply rapidly on foods with lots of protein or carbohydrates when food
temperature is between 5 °C and 60 °C, which is often known as the “food danger
zone”. Therefore, most foodborne illnesses and outbreaks are reported during the
summer months.
Bacteria grow and multiply on some types of food more easily than on others. The
types of foods that bacteria prefer include meat, poultry, dairy products, eggs, seafood,
cooked rice, prepared fruit and salads. These foods are more likely to be infected by
foodborne bacteria but other foods could also be infected or cross-contaminated by
them if appropriate food safety measures are not taken during preparation, storage,
transportation and handling .
The symptoms of FBDs range from mild and self-limiting (nausea, vomiting and
diarrhoea with or without blood) to debilitating and life-threatening (such as kidney
and liver failure, brain and neural disorders, paralysis and potentially cancers) leading
to long periods of absenteeism from work and premature death. After eating tainted
food, abdominal cramps, diarrhoea and vomiting can start as early as one hour or
within three days depending on the foodborne pathogen, type of toxin and level of
food contamination.
2
Burden of foodborne diseases in the South-East Asia Region
Chemicals and toxins in food
Food adulteration and falsification are still a problem in countries of the WHO SouthEast Asia Region where informal food production and distribution systems are deeply
entrenched at the community level. Adulteration of food is normally observed in its
most crude form where prohibited substances are either added or used to partly or
wholly substitute healthy ingredients or to artificially create the impression of freshness
in stale food. Adulterants may be in solid form, of chemicals, or liquid and made up
of colouring substances. Poisonous colouring agents like auramine, rhodomine b,
malachite green and Sudan red are applied on food items for colouring, brightness
and freshness. This can damage the liver and kidneys sometimes. These agents also
cause stomach cancer, asthma and bladder cancer. Colouring agents such as chrome,
tartazine and erythrosine are used in spices, sauces, juices, lentils and oils, causing
cancer, allergy and respiratory problems. The calcium carbide of industrial grade used
for fruit ripening by unscrupulous traders may contain toxic impurities such as traces
of arsenic and phosphorous, which can be quite harmful for the health and can lead
to various ailments..
Dioxins are byproducts of industrial processes but could also result from natural
phenomena such as volcanic eruptions and forest fires. Human exposure is primarily
through food – mainly meat and dairy products, fish and shellfish. These toxins
accumulate in humans, especially in body fat. Dioxins are toxic to the thyroid gland and
inhibit sperm production, and prolonged exposure leads to accumulation in the body.
The dioxin concentration in breast milk fat directly reflects its concentration in body fat.
Mycotoxins are a group of naturally occurring chemicals produced by certain
moulds or fungi. They can grow on a variety of different crops and foodstuffs including
cereals, nuts, spices and dried fruits. Mycotoxins are produced by several fungi in
foodstuffs and these feed during production, storage and transportation, often under
warm and humid conditions. Mycotoxins of most concern from a food safety perspective
include the aflatoxins, ochratoxin A, fumonisins, trichothecenes and zearalenone.
Aflatoxins are most commonly found in maize and peanuts, and feed as contaminants,
and these can also be found in the milk of animals that are fed aflatoxin-contaminated
feed in the form of aflatoxin M1.
Most natural toxins found in fish are produced by species (spp.) of naturally
occurring marine algae. They accumulate in fish when they feed on the algae or
on other fish that have fed on the algae. Ciguatera fish poisoning is associated with
consumption of toxin-contaminated subtropical and tropical reef fish. Unfortunately,
Burden of foodborne diseases in the South-East Asia Region
3
these toxins are not destroyed by normal cooking or processing. Naturally occurring
cyanogenic glycosides are found in raw or unprocessed cassava (Manihot esculenta),
which can cause nerve damage or death if consumed in quantity.
Food poisoning from the consumption of poisonous wild mushrooms has been
reported frequently during the monsoon season in countries of the South-East Asia
Region. In some episodes, whole families have lost their lives due to consumption of
poisonous wild mushrooms. The majority of fatal mushroom poisoning occurs due to
ingestion of Amanita phalloides – the death cap – due to its high content of Amatoxin, a
potent cytotoxin. Fatal poisoning is usually associated with delayed onset of symptoms,
which are very severe and have a toxic effect on the liver, kidney and nervous system.
Unfortunately, cases remain undiagnosed, under-reported and unpublished as these
happen in rural communities.
Food allergy
Food allergy is an abnormal response to a food triggered by the body’s immune system.
Individuals with food allergies develop symptoms by eating foods that for the vast
majority of the population are part of a healthy diet. Food allergy is a growing problem.
The prevalence of food allergies in the general population has been roughly estimated
to be around 1–3% in adults and 4–6% in children.
Peanut or groundnut allergy occurs early in life (<five years of age) and is believed
to be lifelong. Egg and milk allergies are most common food allergies among infants but
are often outgrown. More than 70 foods have been described as causing food allergies.
Several studies indicate that 75% of allergic reactions among children are due to a
limited number of foods, namely egg, peanuts, milk, fish and nuts. Fruits, vegetables,
nuts and peanuts are responsible for most allergic reactions among adults.
Food allergies are a concern for both the allergic individual and also all involved
in supplying and preparing food, including family and friends, caterers, restaurants
and the food industry. There is no cure for food allergies, so it is important to avoid
the food that cause the allergy. Having the correct information to eat, order food and
shop wisely can make a big difference. People with food allergies have to be extremely
careful about what they eat. Eating away from home is often risky for an allergic person.
Food allergic individuals need to know what to avoid eating. They are dependent
on reliable and easy-to-find information about the ingredients of the foods they buy.
Food labelling is, therefore, very important to those with food allergies as there can be
potentially serious consequences.
4
Burden of foodborne diseases in the South-East Asia Region
Global burden of foodborne
diseases
Foodborne diseases (FBDs) are an important cause of illness and death around the
world. However, the extent and cost of unsafe food, and especially the burden due to
chemical and parasitic contaminants in food, is still not fully known. Epidemiological
data on FBDs and laboratory capacity to detect the cause of FBDs are not available
widely, particularly in the developing world. As a result, many foodborne outbreaks
often go unrecognized, unreported or uninvestigated.
A major problem in addressing food safety concerns is the lack of accurate data/
information regarding the extent and cost of FBDs. Lack of comprehensive data and
information on the burden of FBDs makes it challenging for policy-makers to set public
health priorities and allocate resources. Therefore, the World Health Organization
(WHO) has taken an initiative to carry out an estimation of the global burden of FBDs
and generation of evidence-based data and information that will enable policy-makers
to prioritize and allocate resources for food safety.
Objectives
WHO Department of Food Safety, Zoonoses and Foodborne Diseases together with
its partners launched the initiative to estimate the global burden of FBDs in 2006.
The primary goal of the initiative is to enable policy-makers and other stakeholders
to set appropriate, evidence-based priorities in the area of food safety. After an initial
consultation, WHO established a Foodborne Disease Burden Epidemiology Reference
Group (FERG) in 2007 to lead the initiative. These objectives were to:
••
strengthen the capacity of Member States to conduct the burden of
foodborne disease assessments and to increase the number of Member
States that have undertaken a burden of foodborne disease study;
Burden of foodborne diseases in the South-East Asia Region
5
••
provide estimates on the global burden of FBDs according to age, sex and
regions for a defined list of causative agents of microbial, parasitic and
chemical origin;
••
increase awareness and commitment among Member States for the
implementation of food safety standards; and
••
encourage Member States to use burden of foodborne disease estimates for
cost-effective analyses of prevention, intervention and control measures.
Methodology
These objectives were addressed through the establishment of six task forces, each
pursuing on groups of hazards or select aspects of the methodology. Together with the
WHO Secretariat, these task forces commissioned systematic reviews and other studies
to provide the data from which burden estimates could be calculated.
According to WHO, it was important to provide estimates of foodborne disease
at as localized a level as possible because not all foodborne hazards affect every
country equally. On account of gaps in the information available from certain countries
(especially developing countries), subregional estimates are considered more robust as
they build on the data from several countries in each Region.
The six WHO regions were divided into 14 subregions as shown in Figure 1, based
on five categories considering child and adult mortality rates, as follows:
6
••
Category A: very low child and adult mortality
••
Category B: low child mortality and very low adult mortality
••
Category C: low child mortality and high adult mortality
••
Category D: high child and adult mortality
••
Category E: high child mortality and very high adult mortality
Burden of foodborne diseases in the South-East Asia Region
Figure 1: Categorization of subgroups under WHO regions for estimation of global
burden of foodborne diseases
Source: FERG Report (2015)
The list of countries that were divided into 14 subregions is available in Annex 3. A
country can obtain national estimates by referring to estimates for the subregion to
which it belong.
In addition to providing global and regional estimates, the initiative also sought
to promote actions at a national level. This involved capacity-building through national
foodborne disease burden studies, and encouraging the use of information on the
burden of disease in setting evidence-informed policies. A suite of tools and resources
were created to facilitate national studies on the burden of foodborne diseases and
pilot studies were conducted in four countries (Albania, Japan, Thailand and Uganda).
Thirty-one foodborne hazards causing 32 diseases with 11 diarrhoeal disease
agents (1 virus, 7 bacteria and 3 protozoa), 7 invasive infectious disease agents (1 virus,
5 bacteria and 1 protozoa), 10 helminths and 3 chemicals are included (as shown in
Table 1).
Burden of foodborne diseases in the South-East Asia Region
7
Table 1: Hazards and foodborne diseases considered in studies
Hazards
Diarrhoeal disease Virus (1)
Bacteria (7)
agents
Foodborne diseases
Norovirus
Campylobacter sp., Enteropathogenic E.
coli (EPEC), Enterotoxigenic E. coli (ETEC),
Shiga toxin-producing E. coli, Non-typhoidal
Salmonella enterica, Shigella sp., Vibrio cholerae
(V. cholerae)
Protozoa (3)
Cryptosporidium sp., Entamoeba histolytica,
Giardia sp.
Invasive infectious Virus (1)
Hepatitis virus A (HAV)
Bacteria (5)
Brucella sp., Listeria monocytogenes,
disease agents
Mycobacterium bovis (M. bovis), Salmonella
paratyphi A (S. paratyphi A), Salmonella typhi
(S. typhi)
Protozoan (1)
Toxoplasma gondii
Helminths
Cestodes (3)
Echinococcus granulosus, Echinococcus
multilocularis, Taenia solium (T.solium)
Nematodes (2)
Ascaris sp., Trichinella sp.
Trematodes (5)
Clonorchis sinensis, Fasciola sp., Opisthorchis
sp., Paragonimus sp., intestinal fluke
Chemicals
Toxins and poisons (3) Aflatoxin, Cassava cyanide, Dioxin
Together, the 31 hazards caused an estimated 600 million foodborne illnesses,
420 000 deaths and 33 million disability-adjusted life-years (DALY) in 2010. DALY is
a measure of the overall disease burden expressed as the number of years lost due to
ill-health, disability or early death.
Diarrhoeal diseases are the leading cause of foodborne disease illnesses –
particularly norovirus and Campylobacter spp.. It is estimated that one in 10 people
in the world fall ill every year due to eating contaminated food, as shown in Figure 2.
Foodborne diarrhoeal disease agents caused 230 000 deaths, particularly non-typhoidal
S. enterica (NTS), which causes diarrhoeal and invasive disease. Other major causes of
foodborne deaths were S. typhi, T. solium, hepatitis A virus and aflatoxin.
8
Burden of foodborne diseases in the South-East Asia Region
Figure 2: Burden of foodborne illness
1 in 10 people in the world fall ill every year due to eating contaminated food
Source: FERG Report (2015)
The global burden of FBDs is considerable with marked regional variations. The
burden of FBDs is borne by individuals of all ages, but particularly children under five
years of age and persons living in low-income regions of the world. Nearly 40% of the
foodborne disease burden was among children under five years of age with 18 million
DALY lost due to foodborne diarrhoeal disease agents, particularly NTS and EPEC.
Other foodborne hazards with a substantial contribution to the global burden included
S. typhi and T. solium.
Gaps and limitations
Estimates are based on the best available data at the time of reporting. Identified data
gaps were filled using imputation, assumptions and other methods.
Data gaps were a major hurdle to making estimates of the foodborne disease
burden in these national studies. The global and regional estimates provided by
FERG offer an interim solution until improved surveillance and laboratory capacity is
developed.
It is likely that the true number of illnesses and deaths resulting from FBDs
worldwide is even higher because:
••
many cases of food poisoning go unrecognized and untreated,
••
there are gaps in the collection and reporting of data (especially in
developing countries) on the burden of FBDs,
••
there are other causes beyond the 31 hazards included in this report,
especially in the chemical domain,
••
for certain foodborne hazards, there is still considerable uncertainty
regarding their clinical impact. Current estimates only included symptoms
for which sufficient evidence existed.
Burden of foodborne diseases in the South-East Asia Region
9
WHO is focusing its efforts on supporting national policy-makers and governments
in improving surveillance of FBDs to obtain a clearer picture of the unique local
challenges and implement the right strategies to prevent, detect and manage foodborne
risks.
The report prepared by the WHO Foodborne Disease Burden Epidemiology
Reference Group provides the first estimates of global foodborne disease in terms of
incidence, mortality and disease burden in the form of DALY. This report is the outcome
of 10 years of monumental work by WHO and its donors and partners as well as a
number of individuals contributing to this initiative from around the world. The report
is an essential part of WHO’s efforts to facilitate global prevention, detection and
response to public health threats associated with unsafe food. It is a continuation of
WHO activities dedicated to driving food safety as highlighted during World Health
Day 2015.
An important goal of the FERG initiative and the next step in the process is to
encourage and support countries in undertaking foodborne burden of disease studies,
using consistent WHO tools and processes. Therefore, a guide to national burden of
foodborne diseases study has been briefly mentioned in Annex 2.
10
Burden of foodborne diseases in the South-East Asia Region
Foodborne diseases in the WHO
South-East Asia Region
Home to a quarter of the world’s population, the WHO South-East Asia Region has
the second highest burden of FBDs per population among WHO regions. It has more
than half of the global infections and deaths due to typhoid fever or hepatitis A.
Based on data (2010) from the FERG report, the annual burden of FBDs in the
South-East Asia Region includes more than:
••
150 million illnesses
••
175 000 deaths
••
12 million DALYs.
Figure 3: Top 10 causes of foodborne illnesses in the WHO South-East Asia Region
Campylobacter species
Shigella species
Enterotoxigenic E. coli
Non-typhoidal S. enterica
Norovirus
Enteropathogenic E. coli
Hepatitis A virus
Entamoeba histolytica
Ascaris species
Salmonella typhi
0
5 million
10 million
15 million
20 million
25 million
Source: FERG Report (2015)
Burden of foodborne diseases in the South-East Asia Region
11
As shown in Figure 3, Campylobacter sp. was the leading cause of foodborne illness
with an estimated more than 20 million cases every year in the Region. This was followed
by Shigella sp. and enterotoxigenic Escherichia coli with more than 19 million cases
each. At the fourth spot, NTS was estimated to cause more than 16 million infections.
In aggregate terms, E. coli and S. spp. were the leading causes of foodborne
illnesses. Norovirus and hepatitis A virus also caused significant diseases in the Region.
Amoebiasis caused by Entamoeba histolytica and worm infestation by Ascaris sp. were
the leading parasitic causes of illness due to contaminated food.
Figure 4: Top 10 causes of deaths due to foodborne illnesses in
the WHO South-East Asia Region
Salmonella typhi
Norovirus
Hepatitis A virus
Non-typhoidal S. enterica
Enteropathogenic E. coli
Enterotoxigenic E. coli
Vibrio cholerae
Salmonella paratyphi A
Taenia solium
Campylobacter spp.
0
5 000
10 000
15 000
20 000
25 000
30 000
35 000
Source: FERG Report (2015)
As shown in Figure 4, the leading cause of death due to foodborne diseases in
the Region was S. typhi (more than 32 000 deaths), followed by norovirus (nearly
19 000 deaths) and hepatitis A virus (nearly 18 000 deaths) respectively. NTS at fourth
position was responsible for nearly 16 000 deaths in the Region. EPEC and ETEC caused
more than 15 000 and 10 000 deaths respectively. Cholera (caused by V. cholerae) and
paratyphoid fever (caused by S. paratyphi A) were estimated to have caused more than
7600 and nearly 7500 deaths respectively.
Among the parasites, the pork tapeworm (T. solium) was estimated to cause more
than 6800 deaths annually. Despite being the leading cause of foodborne illness in the
Region, Campylobacter sp. caused only 6700 deaths here.
12
Burden of foodborne diseases in the South-East Asia Region
Going by the estimated burden of FBDs in terms of DALYs in the Region as shown
in Figure 5, S. typhi is the leading cause of ill-health, disability or early death and leads
to the highest number of DALYs (nearly 2.3 million). S. paratyphi A that causes a similar
illness was also estimated to be responsible for more than half a million DALYs every year.
Figure 5: Top 10 causes of DALYs due to foodborne illnesses in the
WHO South-East Asia Region
Salmonella typhi
Norovirus
Enteropathogenic E. coli
Non-typhoidal S. enterica
Hepatitis A virus
Enterotoxigenic E. coli
Taenia solium
Campylobacter spp.
Vibrio cholerae
Salmonella paratyphi A
0
0.5 million
1 million
1.5 million
2 million
2.5 million
Source: FERG Report (2015)
Viral causes of foodborne diseases – norovirus and hepatitis A virus were estimated
to be responsible for nearly 1.3 million and 870 000 DALYs every year.
Interestingly, non-typhoidal S. enterica continued to occupy the fourth position
among the top 10 causes of DALYs and was estimated to be responsible for more than
a million DALYs. EPEC and ETEC were responsible for nearly 1.2 million and 760 000
DALYs respectively.
The pork tapeworm was responsible for nearly 670 000 DALY and Campylobacter
sp. and cholera led to 600 000 and 530 000 DALY respectively.
Foodborne diseases in under-five children
The burden of FBDs in children under five years of age is quite high in the Region as
compared with other WHO regions. As shown in Figure 6, three out of 10 children
suffer from diarrhoea in South-East Asia.
Burden of foodborne diseases in the South-East Asia Region
13
Figure 6: Under-five children suffering from diarrhoea in the
WHO South-East Asia Region
3 in 10 children under five years of age suffer from diarrhoea
Source: FERG Report (2015)
The Region contributes to one third of the global deaths due to diarrhoea in
children under five years of age that could be prevented.
Figure 7: Top 10 causes of foodborne illnesses in children under five years of age in
the South-East Asia Region
Enterotoxigenic E. coli
Enteropathogenic E. coli
Campylobacter spp.
Shigella spp.
Norovirus
Non-typhoidal S. enterica
Ascaris spp.
Giardia spp.
Hepatitis A virus
Entamoeba histolytica
0
2 million
4 million
6 million
8 million
10 million
12 million
Source: FERG Report (2015)
In children under five years of age (as shown in Figure 7), the top three causes of
foodborne illnesses were ETEC (nearly 11 million cases), EPEC (nearly 7.3 million cases)
and Campylobacter sp. (nearly 7 million cases).
Shigella sp., norovirus and NTS caused 5.2, 5 and 4.4 million illnesses respectively
and hepatitis A virus caused nearly 1.4 million cases in children under five years of age.
Among parasitic infections in under-five children, round worm (Ascaris sp.),
giardiasis (Giardia sp.) and amoebiasis (Entamoeba histolytica) caused nearly 3, 1.8 and
1 million illnesses respectively.
14
Burden of foodborne diseases in the South-East Asia Region
Figure 8: Top 10 causes of deaths due to foodborne illnesses in children under five
years of age in the South-East Asia Region
Enteropathogenic E. coli
Salmonella typhi
Norovirus
Non-typhoidal S. enterica
Enterotoxigenic E. coli
Campylobacter spp.
Hepatitis A virus
Shigella spp.
Salmonella paratyphi A
Taenia solium
0
1 000
2 000
3 000
4 000
5 000
6 000
7 000
8 000
Source: FERG report (2015)
As shown in Figure 8, the top three causes of death due to FBDs in children
under five years of age in the Region were EPEC (nearly 7400), S. typhi (6600) and
norovirus (4000).
Other major causes of death in children under five years of age were estimated
to be NTS (3663 deaths), ETEC (3532 deaths), Campylobacter spp. (3322 deaths) and
hepatitis A virus (2805 deaths).
Figure 9: Top 10 causes of DALYs due to foodborne illnesses in children under five
years of age in the South-East Asia Region
Enteropathogenic E. coli
Salmonella typhi
Norovirus
Non-typhoidal S. enterica
Enterotoxigenic E. coli
Campylobacter spp.
Hepatitis A virus
Shigella spp.
Dioxin
Ascaris spp.
0
100 000 200 000 300 000 400 000 500 000 600 000 700 000 800 000
Source: FERG report (2015)
Burden of foodborne diseases in the South-East Asia Region
15
In terms of DALY due to FBDs in children under five years of age (as shown in
Figure 9), the leading cause was EPEC (nearly 674 000 DALY), followed by S. typhi
(610 000 DALY) and norovirus (nearly 364 000 DALY).
Other causes of DALYs include NTS, ETEC, Campylobacter sp. hepatitis A virus,
Shigella sp. and dioxin. Interestingly, dioxin was estimated to have a significant impact
in children under five years of age in the Region with more than 160 000 DALYs. It
was based on the result of breast milk testing for a persistent organic pollutants (POPs)
study carried out in India under the Global Environmental Monitoring System (GEMS).
16
Burden of foodborne diseases in the South-East Asia Region
Conclusions and action points
The most comprehensive report to date on the impact of contaminated food on health
and well-being is titled ‘Estimates of the Global Burden of Foodborne Diseases’. These
estimates are the result of a decade of work, including inputs from more than 100
experts from around the world. Based on what we know now, it is apparent that the
global burden of FBDs is considerable. The FERG report highlights the global threat
posed by FBDs in the context of globalization of the food trade. Unsafe food endangers
everyone and billions of people are at risk.
The global burden of FBDs is considerable with marked regional variations. The
burden of FBDs is borne by individuals of all ages, and particularly children under five
years of age and persons living in low-income regions of the world. These estimates
are conservative; further studies are needed to address the data gaps and limitations
of this study. The considerable difference in the burden of foodborne disease between
low- and high-income regions suggests that a major proportion of the current burden
is avoidable and that control methods do exist.
The report highlights that action to reduce illnesses and deaths from FBDs must
be tailored according to regional and national needs as the types of contaminants and
reasons for their prevalence differ across the world. The report will support policymakers in implementing the right strategies to prevent, detect and manage foodborne
risks to improve food safety.
The report will enable governments achieve the Sustainable Development Goal
2 for food security and nutrition (target 2.1: “By 2030, end hunger and ensure access
by all people, in particular the poor and people in vulnerable situations, including
infants, to safe, nutritious and sufficient food all year round”). The achievement of Goal
3 (Ensure healthy lives and promote well-being for all at all ages); Goal 1 (End Poverty
in all its forms everywhere) and Goal 8 (Promote sustained, inclusive and sustainable
Burden of foodborne diseases in the South-East Asia Region
17
economic growth, full and productive employment and decent work for all) will also
be cited through promoting the safety of food supply domestically and internationally.
The report also reinforces the need for governments, the food industry and
individuals to do more to make food safe and prevent foodborne illnesses and
intoxications. Safe drinking water, good hygienic practices and improved sanitation
are keys for preventing foodborne illnesses and intoxications.
The majority of FBDs and deaths are preventable. Food safety is a public health
priority and governments should develop policies and regulatory frameworks to establish
and implement effective food safety systems. Food safety systems should ensure that
food producers and suppliers along the whole food chain operate responsibly and
supply safe food to consumers.
Food safety is a shared responsibility. All food operators and consumers should
understand the roles they must play to protect their health and that of the wider
community. All stakeholders can contribute to improvements in food safety throughout
the food chain by incorporating these estimates into policy development at the national
and international levels.
Think globally, act locally: while there is no single, global solution to the problem
of FBDs, a strengthened food safety system in one country will positively impact the
safety of food in other countries. There is need for coordinated, cross-border action
across the entire food supply chain.
Coordinated action at the global, regional and national levels is needed to address
risks of FBDs and ensure food safety. Education and training are needed on prevention
of FBDs among food producers, suppliers, handlers and the general public, including
women and school children.
Key action points towards ensuring food safety in the Region include the conduct
of national studies on the burden of FBDs, strengthening of laboratory capacity to be
able to detect FBDs, and strengthening the surveillance of FBDs, including the collation
of local data to validate regional estimates and translation of estimates of FBDs into
food safety policy.
The International Health Regulations (IHR 2005) is a legally binding instrument to
ensure global health security. It calls upon WHO Member States to build core capacities
for implementation of IHR (2005), including food safety events. The evaluation of IHR
self-assessment done by 11 Member States of the WHO South-East Asia Region in
18
Burden of foodborne diseases in the South-East Asia Region
2015 clearly illustrates that most Member States have limited capacity for surveillance,
assessment and management of priority food safety events. Therefore, the WHO
Regional Office for South-East Asia is providing technical support to Member States
to evaluate existing national foodborne disease surveillance systems, including risk
assessment and the management of food safety events, and to identify action plans to
improve surveillance, assessment and management of priority FBDs and food safety
events.
WHO is working with governments and partners to reduce the level of food
contamination throughout different stages of the food-chain. These stages include
the point of final consumption to the levels at which the exposure to pathogens and
contaminants does not pose significant risks for human health.
WHO promotes the use of international platforms such as the joint WHO-FAO
(Food and Agriculture Organization of the United Nations) International Food Safety
Authorities Network (INFOSAN) to ensure effective and rapid communication during
food safety emergencies. WHO also works closely with other international organizations
to ensure food safety along the entire food-chain, from production to consumption,
in line with the Codex Alimentarius (CA). CA is a collection of international food
standards, guidelines and codes of practice covering all main foods and steps in the
food supply chain.
FBDs are preventable. WHO is promoting the important role that everyone can
play to promote food safety through systematic disease prevention and awareness
programmes. WHO’s Five Keys to Safer Food explains the basic principles that each
individual should know all over the world to prevent FBDs:
(1) Keep clean
––
thoroughly wash raw fruits and vegetables with tap water.
––
keep clean hands, kitchen and chopping board all the time.
(2) Separate raw and cooked food
––
do not mix raw food and ready-to-eat food.
––
do not mix raw meat, fish and raw vegetables.
(3) Cook thoroughly
––
thoroughly cook all meat, poultry and seafood, especially shellfish.
––
reheat all leftovers until they are steaming hot.
Burden of foodborne diseases in the South-East Asia Region
19
(4) Keep food at safe temperatures
––
refrigerate cooked food within two hours of preparation.
––
never defrost food at room temperature; defrost frozen food in the
refrigerator, cold water or the microwave.
(5) Use safe water and raw materials
20
––
use safe drinking water for food preparation.
––
check use-by dates and labels while buying packed food.
Burden of foodborne diseases in the South-East Asia Region
Burden of foodborne diseases in the South-East Asia Region
21
Etiologic agent or
cause
Incubation
period (latency)
Signs and
symptoms
Cadmium in plated
utensils
Cadmium poisoning
From 15 to 30
minutes
From a few
minutes to 1 hour
From 30 minutes
to 2 hours
Nausea, vomiting,
abdominal pains,
diarrhoea, shock
Vomiting, abdominal
pains, diarrhoea
Nausea, vomiting,
retching, diarrhoea,
abdominal pains
Very acid foods
and drinks, candies
and other cake
decorations
Very acid food and
beverages
Many varieties of
wild mushrooms
2
Food implicated
1 Adapted and modified from Instituto Panamericano de Protección de Alimentos y Zoonosis (INPPAZ) – Pan American Health Organization WHO
2 Samples should be collected from any of the listed foods that have been ingested during the incubation period of the disease.
Antimony in
enamelled iron
utensils
Possibly resin-type
substances found
in some types of
mushrooms
Antimony poisoning
Chemical agents
Poisoning by
mushrooms of the
group that causes
gastrointestinal irritation
Fungal agents
1.1 Incubation period tends to be less than 1 hour
1. Initial or major signs and symptoms of the upper digestive tracts (nausea, vomiting)
Disease
Classification of foodborne diseases1
Annex 1
Vomit, stool,
urine and blood
Vomit, stool and
urine
Vomit
Specimens to
be obtained
Use of utensils that
contain cadmium,
storage of very acid
food in containers that
contain cadmium,
ingestion of foods that
contain cadmium
Use of utensils that
contain antimony,
storage of very acid
food in enamelled iron
utensils
Ingestion of unknown
toxic varieties of
mushrooms, through
confusion with other
edible varieties
Contributing factors
22
Burden of foodborne diseases in the South-East Asia Region
Copper in pipes
and utensils
Sodium fluoride in
insecticides
Lead contained in
earthenware pots,
pesticides, paints,
plaster and putty
Tin in tin cans
Zinc in galvanized
containers
Fluoride poisoning
(fluorosis)
Lead poisoning
Tin poisoning
Zinc poisoning
Etiologic agent or
cause
Copper poisoning
Disease
From a few
minutes to 2 hours
Mouth and
abdominal pains,
nausea, vomiting,
dizziness
Swelling, nausea,
vomiting, abdominal
pains, diarrhoea,
headache
Metallic taste,
burning in the
mouth, abdominal
pains, milky vomit,
black stool or
presence of blood,
bad breath, shock,
blue line at the edge
of gums ("lead line")
30 minutes or
more
From 30 minutes
to 2 hours
Salty or soapy
taste, numbness
in the mouth,
vomiting, diarrhoea,
abdominal pains,
pallour, cyanosis,
dilated pupils,
spasms, collapse,
shock
Metallic taste,
nausea, vomiting
(green vomit),
abdominal pains,
diarrhoea
Signs and
symptoms
From a few
minutes to 2 hours
From a few
minutes to a few
hours
Incubation
period (latency)
Very acid food and
beverages
Very acid foods and
beverages
Vomit, gastric
lavages, urine,
blood and stool
Storage of very acid food
in galvanized tins
Storage of acid foods in
unlined tin containers
Use of vessels containing
lead, storage of very
acid food in vessels
containing lead, storage
of pesticides in the same
place as food
Vomit, gastric
lavages, stool,
blood and urine
Vomiting, stool,
urine and blood
Storage of insecticides in
the same place as food,
confusion of pesticides
with powdered foods
Vomit and gastric
lavages
Any accidentally
contaminated
food, particularly
dry food such as
powdered milk,
flour, baking
powder and cake
mixes
Very acid food
and beverages
stored in vessels
containing lead,
any accidentally
contaminated food
Storage of very acid
food in copper utensils
or use of copper tubing
in serving very acid
beverages, defective
valves on devices
to prevent reflux (in
dispensers)
Contributing factors
Vomit, gastric
lavage, urine and
blood
Specimens to
be obtained
Very acid food and
beverages
Food implicated
Burden of foodborne diseases in the South-East Asia Region
23
Etiologic agent or
cause
Nausea, vomiting,
cyanosis, headache,
dizziness,
weakness, loss of
consciousness,
chocolate-coloured
blood
Nausea, vomiting,
retching, abdominal
pains, diarrhoea,
prostration
From 1 to 8 hours,
average of 2 to 4
hours
From 1 to 2 hours
Nausea, vomiting,
occasionally
diarrhoea
Signs and
symptoms
From ½ to 5 hours
Incubation
period (latency)
Cured meats,
any accidentally
contaminated
food and exposure
to excessive
nitrification
Ham, beef or
poultry products,
cream-filled
pastries, food mixes
and leftover food
Cooked or fried
rice and plates of
rice with meat
Food implicated
Use of excessive quantities
of nitrites or nitrates to
cure food or conceal
spoilage, confusion of
nitrites with common salt,
and other condiments,
inadequate refrigeration,
excessive nitrification in
fertilized food
Inadequate refrigeration,
handler touched cooked
food, preparation of
food several hours
before serving,
handlers with purulent
infections, food kept
at warm temperatures
(bacterial incubation),
fermentation of foods
abnormally low in acids
Patient: vomit,
stool, rectal swab.
Carrier: nasal
swabs, swabs
from lesion, and
rectal swabs
Blood
Storage of cooked food
at warm temperatures,
food cooked in large
containers, food
prepared several hours
before serving
Contributing factors
Vomit and stool
Specimens to
be obtained
3 Carbon monoxide poisoning can resemble some of the diseases included in this category. Patients who have been inside a closed automobile with the motor running or who have been in heated rooms with poor
ventilation are at risk of exposure to carbon monoxide.
Nitrite poisoning
Nitrites or nitrates
used as compounds
to cure meat, or
water from shallow
wells
Exoenterotoxins
A, B, C, D and E
of Staphylococcus
aureus.
Staphylococci from
the nose, skin, and
lesions of infected
people and animals,
and infected udders
of cows
Staphylococcal food
poisoning
Chemical agents 3
Exoenterotoxin of
B. cereus
Bacillus cereus
gastroenteritis (type
emetic)
Bacterial agents
1.2 Incubation period of 1 to 6 hours
Disease
24
Burden of foodborne diseases in the South-East Asia Region
Okadaico acid
and other toxins
produced by
dinoflagellates of
the Dinophysis spp.
Etiologic agent or
cause
Norovirus (Norwalk-like
viruses)
Viral agent
Poisoning caused by
mushrooms of the
cyclopeptide and
Giromitra groups
Fungal agents
From 6 to 24
hours
Norovirus viruses
12 to 48 hours
are relatively stable
in the environment
and can survive
freezing and heating
to 60°C
Cyclopeptides
and gyromitrine
found in certain
mushrooms
Incubation
period (latency)
From 1/2 to 12
hours, usually 4
hours
1.3 Incubation period usually from 7 to 12 hours
Diarrheal shellfish
poisoning (DSP)
Disease
Vomiting, watery,
non-bloody
diarrhoea with
abdominal cramps,
low-grade fever,
myalgia, malaise,
headache
Abdominal pains,
feeling of fullness,
vomiting, prolonged
diarrhoea, loss
of strength,
thirst, muscle
cramps, rapid
and weak pulse,
collapse, jaundice,
somnolence, dilated
pupils, coma, death
Diarrhoea, nausea,
abdominal pains
Signs and
symptoms
Contaminated food
or water
Amanita phalloides,
A. verna, Galerina
autumnalis.
Esculenta giromitra
(false colmenilla)
and similar spp. of
mushrooms
Mussels, clams,
oysters
Food implicated
Stool specimens
taken within
48 to 72 hours
after onset of
symptoms
Urine, blood,
vomit
Gastric rinse
Specimens to
be obtained
Direct person-to-person
spread or faecally
contaminated food or
water, touching surfaces
or objects contaminated
with norovirus,
noroviruses can also
spread via a droplet
route from vomitus.
Ingestion of certain
spp. of Amanita,
Galerina and Giromitra
mushrooms, ingestion
of unknown varieties of
mushrooms, confusion
of toxic mushrooms with
edible varieties
Shellfish caught in water
with high concentration
of Dynophysis spp.
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
25
Includes
adenovirus,
coronavirus,
rotavirus,
parvovirus, and
astrovirus
Etiologic agent or
cause
½ to 3 days,
usually 36 hours
Incubation
period (latency)
Sodium hydroxide
(caustic soda) in
compounds used
to wash bottles,
detergent, drain
cleaners, hairrelaxants
Sodium hydroxide
poisoning
Infections by betahaemolytic streptococci
Bacterial agents
Burning of the lips,
mouth and throat;
vomiting, abdominal
pains, diarrhoea
A few minutes
Pharyngitis, fever,
nausea, vomiting,
rhinorrhoea,
sometimes rash
Burning in the
tongue, mouth, and
throat, vomiting
Nausea, vomiting,
diarrhoea,
abdominal pain,
myalgia, headache,
light fever. Duration:
36 hours
Signs and
symptoms
A few minutes
Streptococcus
From 1 to 3 days
pyogenes of the
throat and lesions of
infected people
2.2 Incubation period from 18 to 72 hours
Freezing mixtures of
calcium chloride for
freezing desserts
Calcium chloride
poisoning
Chemical agents
2.1 Incubation period less than 1 hour
2. Manifestation of pharyngitis and respiratory signs and symptoms
Small round viruses,
productive of
gastroenteritis
Disease
Specimens to
be obtained
Raw milk, foods
containing egg
Bottled beverages
Frozen desserts
Improper rinsing of
bottles washed with
caustic substances
Contamination of
popsicles during
freezing, permitting the
introduction of calcium
chloride in the syrup
Infected people who
touch food ready for
consumption, harvest
of shellfish from
contaminated waters,
improper disposal
of wastes, use of
contaminated water
Contributing factors
Pharyngeal swabs, Workers who touched
vomit
cooked food, workers
with purulent infections,
inadequate refrigeration,
improper cooking or
reheating, preparation
of food several hours
before serving
Vomit
Vomit
Shellfish from
Stool, blood
contaminated water in acute and
convalescent
phases
Food implicated
26
Burden of foodborne diseases in the South-East Asia Region
Etiologic agent or
cause
Coxiella burnetii
2-3 weeks (3-30
days)
Incubation
period (latency)
Chills, headache,
malaise, myalgia and
sweets
Signs and
symptoms
Endoenterotoxin
formed during the
sporulation of C.
perfringens in the
intestines, the
body, in human or
animals faeces or in
the soil
Gastroenteritis caused
by Clostridium
perfringens
From 8 to 22
hours (average of
10 hours)
Exoenterotoxin of B. From 8 to 16
cereus, organisms in hours (average of
the soil
12 hours)
Gastroenteritis
by Bacillus cereus
(diarrheal type)
Bacterial agents
3.1 Incubation period usually from 7 to 12 hours
Abdominal pains,
diarrhoea
Nausea, abdominal
pains, diarrhoea
Specimens to
be obtained
Cooked beef or
poultry, broths,
sauces and soups
Foods made
from grains, rice,
custard, sauces,
meatballs, sausages,
cooked vegetables,
dehydrated or
reconstituted
products
Stool
Stool
Serum
Raw milk from
infected cattle or
goats, direct contact
with contaminated
materials
Food implicated
3. Initial or major signs and symptoms of the lower digestive tract (abdominal pains, diarrhoea)
Q Fever
Rickettsial agent
2.3 Incubation period from 3 to 30 days
Disease
Inadequate refrigeration,
storage of food at warm
temperatures (bacterial
incubation), preparation
of food several hours
before serving, improper
reheating of leftover
food
Inadequate refrigeration,
storage of food at warm
temperatures (bacterial
incubation), preparation
of food several hours
before serving, improper
reheating of leftovers
Consumption of raw
milk, direct contact
with aborted materials,
inadequate disinfection
and disposal of aborted
materials
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
27
Etiologic agent or
cause
Incubation
period (latency)
Endoenterotoxin of
V. cholerae classical
and El Tor biotypes,
from faeces of
infected persons
Campylobacter
jejuni
Campylobacter
Infection
Cholera
Aeromonas
hydrophila
Diarrheal diseases
caused by Aeromonas
Bacterial agents
Watery diarrhoea,
abdominal pain,
nausea, headache
Abdominal pains,
diarrhoea (frequently
with mucus and
blood), headache,
myalgia, fever,
anorexia, nausea,
vomiting. Sequellae:
Guillian-Barre
syndrome
Severe, watery
diarrhoea (rice water
stools), vomiting,
abdominal pains,
dehydration, thirst,
collapse, loss of
skin tone, shrivelled
fingers, sunken eyes
2 to 7 days usually
between 3 and 5
From 1 to 3 days
Signs and
symptoms
1 to 2 days
3.2 Incubation period usually from 18 to 72 hours
Disease
Harvesting of fish and
shellfish from water
contaminated with
sewage in endemic
areas, poor personal
hygiene, infected
handlers who touched
food, inadequate
cooking, use of
contaminated water in
washing or rinsing food,
improper disposal of
wastewater, use of waste
from latrines as fertilizer
Stool
Raw fish and
shellfish, food
washed or
prepared with
contaminated
water, water
Drinking raw milk,
handling raw products,
eating raw or
undercooked poultry,
inadequate cooking or
pasteurization, crosscontamination with raw
meat
Stool or rectal
swabs, blood
Raw milk, beef
liver, raw clams
Contamination of food
in sea or surface water
Contributing factors
Stool
Specimens to
be obtained
Fish, shellfish,
snails, water
Food implicated
28
Burden of foodborne diseases in the South-East Asia Region
Cholera like vibrio
E. coli O157:H7,
O26, O111, O115,
O113
Strains of
Enteroinvasive
E. coli
Diarrhoeal
diseases caused by
Enterohaemorrhagic
Escherichia coli
Diarrhoea caused
by Enteroinvasive
Escherichia coli
Etiologic agent or
cause
Gastroenteritis caused
by cholera like vibrio
Disease
½ to 3 days
1 to 10 days
usually 2 to 5 days
From 5 to 48
hours, average
from 10 to 24
hours
Incubation
period (latency)
Severe abdominal
pain, fever, watery
diarrhoea, (usually
with mucus and
blood present)
tenesmus
Watery diarrhoea
followed by bloody
diarrhoea, severe
abdominal pain,
blood in the
urine. Sequelae:
Haemolytic uremic
syndrome (HUS)
Abdominal pains,
diarrhoea, nausea,
vomiting, fever,
chills, headache,
myalgia
Signs and
symptoms
Hamburger made
from meat of infected
animals, consumption
of raw meat and milk,
inadequate cooking,
cross-contamination,
infected people
touching food ready for
consumption, improper
desiccation and
fermentation of meats
Inadequate cooking,
infected persons
touching food ready
for consumption, not
washing hands after
defecation, storing food
at room temperature,
storing food in the
refrigerator in large
containers, preparing
food several hours
before serving, improper
reheating of food
Stool, rectal
swabs
Stool, rectal
swabs
Hamburger, raw
milk, sausages,
yogurt, lettuce,
water
Salads and other
food that are not
subsequently
treated, water
Infected handlers who
touch food, insufficient
cooling, incomplete
cooking, improper
cleaning and disinfection
of equipment
Contributing factors
Stool, rectal
swabs
Specimens to
be obtained
Various foods,
water
Food implicated
Burden of foodborne diseases in the South-East Asia Region
29
Pleisomonas
shigeloides
Various serotypes
of Salmonella from
faeces of infected
people and animals
Salmonellosis
Strains of ETEC
Etiologic agent or
cause
Enteritis by Plesiomonas
Diarrhoea caused by
ETEC
Disease
From 6 to 72
hours, average
from 18 to 36
hours
1 to 2 days
½ to 3 days
Incubation
period (latency)
Water
Beef and poultry
and their byproducts, egg
products, other
foods contaminated
with salmonellae
Abdominal pains,
diarrhoea, chills,
fever, nausea,
vomiting, malaise
Salads and other
food that are not
subsequently
thermally treated,
fresh cheeses,
water
Food implicated
Diarrhoea with
mucus and blood in
the stool
Profuse watery
diarrhoea (without
mucus or blood)
abdominal
pain, vomiting,
prostration,
dehydration, light
fever
Signs and
symptoms
Inadequate cooking
Inadequate refrigeration,
storage of food at
warm temperatures
(bacterial incubation),
inadequate cooking and
reheating, preparation
of food several hours
before serving, crosscontamination, improper
cleaning of equipment,
infected handlers who
touch cooked food,
acquisition of food from
contaminated sources.
Stool, rectal
swabs
Inadequate cooking,
infected people
touching food ready
for consumption, not
washing hands after
defecation, storage
of food at room
temperature, keeping
food in the refrigerator
in large containers,
preparing food several
hours before serving,
improper reheating of
food, use of raw milk in
making cheese
Contributing factors
Stool, rectal
swabs
Stool, rectal
swabs
Specimens to
be obtained
30
Burden of foodborne diseases in the South-East Asia Region
Yersinia
enterocolitica
Diarrhoea caused by
yersiniosis
From 3 to 5 days
1 to 7 days
From 2 to 48
hours, average 12
hours
From ½ to 7 days,
usually from 1 to
3 days
Incubation
period (latency)
Ascariasis
Parasitic agents
Ascaris lumbricoides
14 to 20 days
3.3 Incubation period from a few days to several weeks
Viral gastroenteritis
Enteric viruses
(echovirus,
coxsackievirus,
reovirus,
adenovirus)
V. parahaemolyticus
from sea water or
marine products
Gastroenteritis caused
by V. parahaemolyticus
Viral agents
Shigella flexneri,
S. dysenteriae, S.
sonnei and S. boydii
Etiologic agent or
cause
Shigellosis
Disease
Stool, rectal
swabs
Raw or
contaminated sea
food, shellfish
Stomach disorders,
cramps, vomiting,
fever
Diarrhoea, fever,
vomiting, abdominal
pains, sometimes
respiratory
symptoms
Vegetables and
water
Food ready for
consumption
Stool
Stool
Stool, rectal
swabs
Stool, rectal
swabs
Specimens to
be obtained
Any food ready
for consumption
that becomes
contaminated,
frequently salads,
water
Food implicated
Abdominal pains
Raw milk, water
(can simulate
appendicitis), light
fever, headache,
discomfort, anorexia,
nausea, vomiting
Abdominal pains,
diarrhoea, nausea,
vomiting, fever,
chills, headache
Abdominal pains,
diarrhoea, mucoid
faeces with blood
present, fever
Signs and
symptoms
Inadequate waste
disposal, poor hygiene in
food handling
Poor personal hygiene,
infected workers
touching food, improper
cooking and reheating
Inadequate cooking
or pasteurization,
cross-contamination,
contaminated
ingredients or water
Inadequate cooking,
inadequate refrigeration,
cross-contamination,
improper cleaning of
equipment, use of sea
water in preparing food
Infected handlers
touching the food,
inadequate refrigeration,
improper cooking and
reheating
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
31
Entamoeba
histolytica
Giardia lamblia
from faeces of
infected people
Cryptosporidium
parvum
Echinococcus
granulosus,
Echinococcus
multilocularis
Fasciola hepatica
Giardiasis
Cryptosporidiosis
Hydatidosis (unilocular
or multilocular)
Liverfluke (Fascioliasis)
Etiologic agent or
cause
Amoebic dysentery
(amoebiasis)
Disease
From 4 to 6 weeks
Months to years
1 to 12 days,
usually 7 days
From 1 to 6 weeks
From a few days
to several months
usually between 2
and 4 weeks
Incubation
period (latency)
Dyspepsia, fever,
right upper quadrant
pain, anorexia,
hepatomegaly,
splenomegaly,
ascites, urticaria,
respiratory
symptoms, and
jaundice
Abdominal pain,
abnormal abdominal
tenderness,
hepatomegaly with
an abdominal mass,
jaundice, fever
Profuse watery
diarrhoea,
abdominal pain,
anorexia, vomiting,
light fever
Abdominal pains,
diarrhoea with
mucus, fatty stools
Abdominal pains,
constipation or
diarrhoea with blood
and mucus
Signs and
symptoms
Biopsy or serum
Food or water
contaminated with
faeces of infected
dog, fox
Stool, tissue
biopsy
Stool, intestinal
biopsy
Apple cider, water
Aquatic plants or
plants with high
moisture content
Stool
Stool
Specimens to
be obtained
Raw fruits and
vegetables, water
Vegetables and raw
fruits
Food implicated
Eating raw aquatic
plants, inefficient
disposal of human and
animal wastes in pond or
water bodies
Consumption of raw
vegetables or water
contaminated with
faeces of infected dog
or fox
Improper disposal
of animal wastes,
contamination from the
animal environment,
inadequate filtering of
water
Poor personal hygiene,
infected handlers
touching food, improper
cooking, improper waste
water disposal
Poor personal hygiene,
infected handlers
touching the food,
improper cooking and
reheating
Contributing factors
32
Burden of foodborne diseases in the South-East Asia Region
O. viverrine, O.
felineus
Fasciolopsis buksi,
Echinostoma
Paragonimus
westermani
T. solium from
infected pork
Intestinal fluke
(Fasciolopsis)
Lung fluke
(Paragonimiasis)
Taeniasis due to Taenia
solium (pork tapeworm)
Etiologic agent or
cause
Opisthorchiasis
Disease
From 3 to 6 weeks
2–15 days
6–8 weeks
From 4 to 5 weeks
Incubation
period (latency)
General malaise,
hunger, weight loss
Cough, fever, bloody
sputum, loss of
appetite, chest pain,
and headache
Chronic stage:
productive cough
with brownish
sputum, chest pain,
and night sweats
Diarrhoea,
constipation,
abdominal
pain, dizziness,
and headache,
sometimes vomiting,
fever, nausea, and
allergic reactions
such as oedema of
the face
Flatulence, fatigue,
dyspepsia, right
upper quadrant
abdominal pain,
anorexia, and mild
hepatomegaly
Signs and
symptoms
Sputum, stool
Raw or
undercooked crab
or crayfish
Stool
Stool
Raw or
undercooked
aquatic plants
Raw or
undercooked pork
Stool
Specimens to
be obtained
raw or
undercooked fish
Food implicated
Failure to inspect meat,
improper cooking,
improper wastewater
disposal, grasses
contaminated by waste
water
Crab or crayfish
consumed raw or
prepared only in vinegar,
brine, or wine without
cooking
Consuming raw
aquatic plants, faecal
contamination (from
humans or pigs) of water
where aquatic plants are
grown
Consuming raw or
undercooked fish and
improper sanitary
disposal of faeces
facilitate infestation of
fish in ponds
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
33
Diphyllobothrium
latum from flesh of
infected fish
Diphyllobotriasis (fish
tapeworm infection)
Undefined
gastrointestinal
discomfort, anaemia
may occur
From 3 to 6 weeks
painful oedema,
seizures,
hemiparesis, and
headaches
Stomach pain,
nausea, vomiting,
abdominal pain
General malaise,
hunger, weight loss,
abdominal pains
Signs and
symptoms
From 4 to 6 weeks
From 8 to 14
weeks
Incubation
period (latency)
Mushroom poisoning
from the group that
contains ibotenic acid
Fungal agents
Ibotenic and
muscimol found in
certain mushrooms
From 30 to 60
minutes
4.1 Incubation period tends to be less than 1 hour
Somnolence and
state of intoxication,
confusion, muscular
spasms, delirium,
visual disorders
4. Manifestation of neurological signs and symptoms (visual disorders, tingling, paralysis)
Spirometra spp.
Anisakis
pseudoterranova
Anisakiasis
Sparganosis
T. saginata from
meat from meat of
infected cattle
Etiologic agent or
cause
Taeniasis due to
Taenia saginata (beef
tapeworm)
Disease
Amanita
muscaria, A.
pantherina, and
related spp. of
mushrooms
Contaminated
water, consuming
raw flesh of frog or
snake
Ingestion of Amanita
muscaria and related
spp. of mushrooms,
ingestion of unknown
varieties of mushrooms,
confusion of toxic
mushrooms with edible
varieties
Drinking water
contaminated with
infected copepods
or consuming raw or
under-cooked flesh of
frog or snake
Biopsy
Inadequate cooking,
improper wastewater
disposal, lakes
contaminated by waste
water
Stool
Ingestion of raw or
undercooked fish
Stool
Rock fish, herring,
cod, salmon, squid,
sushi
Raw or
undercooked fresh
water fish
Failure to inspect meat,
improper cooking,
improper wastewater
disposal, pasture
contaminated by waste
water
Contributing factors
Stool
Specimens to
be obtained
Raw or
undercooked meat
Food implicated
34
Burden of foodborne diseases in the South-East Asia Region
Organophosphorus
insecticides, such
as parathion, TEPP,
diazinon, malathion
Carbaryl (sevin),
Temik (aldicarb)
Carbamate poisoning
Muscarine found in
certain mushrooms
Etiologic agent or
cause
Organophosphorus
poisoning
Chemical agents
Poisoning caused
by mushrooms
of the group that
contains muscarine
(muscarinism)
Disease
½ hour
From a few
minutes to a few
hours
15 minutes to a
few hours
Incubation
period (latency)
Epigastric pain,
vomiting, abnormal
salivation,
contraction of
the pupils, lack
of muscular
coordination
Nausea, vomiting,
abdominal
pains, diarrhoea,
headache,
nervousness, blurred
vision, chest pains,
cyanosis, confusion,
spasmodic
contraction,
convulsions
Excessive salivation, perspiration,
lacrimation, drop
in blood pressure,
irregular pulse,
contraction of the
pupils, blurred
vision, asthmatic
breathing
Signs and
symptoms
Any accidentally
contaminated food
Any accidentally
contaminated food
Clitocybe dealbata, C. rivulose,
and many spp. of
Inocybe and Boletus mushrooms
Food implicated
Blood, urine
Blood, urine,
adipose tissue (for
biopsy)
Vomit
Specimens to
be obtained
Improper application
to crops, storage in the
same areas as food,
mistaken as food in
powdered form
Spraying of crops
immediately before
harvest, storage of
insecticides in the same
place as food, confusion
of pesticides with food in
powdered form
Ingestion of A.
muscaria and related
spp., consumption
of unknown varieties
of mushrooms,
consumption of toxic
mushrooms by mistake
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
35
Jimsonweed (thorn
apple) poisoning
Poisonous plants Tropane alkaloids
found in Datura
stramonium
Less than 1 hour
Tetrodoxin found in From 10 minutes
to 3 hours
the intestines and
gonads of puffer fish
(blowfish, globefish)
Tetrodotoxism
(tetraodon poisoning)
Several minutes to
30 minutes
Incubation
period (latency)
Saxitoxin and
other dinoflagellate
toxins of the spp.
Alexandrium and
Gymnodinium
Etiologic agent or
cause
Paralytic Shellfish
Poisoning
Dinoflagellates
Disease
Abnormal thirst,
photophobia,
distorted vision,
difficulty speaking,
delirium, facial
flushing, delirium,
coma, rapid pulse
heart attack.
Sensation of
tingling in the
fingers and toes,
dizziness, pallor,
numbness of the
mouth and limbs,
gastrointestinal
symptoms,
haemorrhage and
flaking of the skin,
fixation of the
eyes, spasmodic
contraction,
paralysis, cyanosis
Tingling, burning,
and numbness
around the lips
and the tips of the
fingers, dizzy spells,
incoherent speech,
respiratory paralysis
Signs and
symptoms
Urine
Stool
Fish of the puffer
fish family
Any part of the
herb, tomatoes
grown with grafts
Gastric lavage
Specimens to
be obtained
Mussels and clams
Food implicated
Consumption of any
part of the Jimson weed
or consumption of
tomatoes grown with
grafts
Ingestion of fish of
the puffer fish family,
consumption of such
fish without extracting
intestines and gonads
Harvesting shellfish
from water with high
concentrations of
dinoflagellates of the
spp. Alexandrium and
Gymnodinium
Contributing factors
36
Burden of foodborne diseases in the South-East Asia Region
Resin or cicutoxin
found in water
hemlock
Etiologic agent or
cause
From 15 to 60
minutes
Incubation
period (latency)
Ciguatera poisoning
Marine plankton
Chlorinated
hydrocarbon poisoning
Chemical agents
Ciguatoxin from
the intestines, roe,
gonads, and flesh of
tropical marine fish
From 3 to 5 hours,
sometimes more
From 30 minutes
Insecticides
to 6 hours
containing
chlorinated
hydrocarbon, such
as aldrin, chlordane,
DDT, dieldrin,
endrin, lindane,
and toxaphene
4.2 Incubation period usually between 1 and 6 hours
Water hemlock
poisoning
Disease
Tingling and
numbness around
the mouth, metallic
taste, dryness
of the mouth,
gastrointestinal
symptoms, watery
stool, myalgia,
dizziness, dilated
pupils, blurred
vision, prostration,
paralysis
Nausea, vomiting,
paresthesia,
dizziness, muscular
weakness, anorexia,
weight loss,
confusion
Excessive salivation,
nausea, vomiting,
stomach pains,
frothing at the
mouth, irregular
breathing,
convulsions,
respiratory paralysis
Signs and
symptoms
Numerous varieties
of tropical fish
Any accidentally
contaminated food
Root of water
hemlock (Cicuta
virosaand C.
masculata)
Food implicated
Blood, urine,
stool, gastric
lavages
Urine
Specimens to
be obtained
Ingestion of liver,
intestines, roe, gonads,
or flesh of tropical reef
fish; in general the large
reef fish are more likely
to be toxic
Storage of insecticides in
the same place as food,
confusion of pesticides
with food in powdered
form
Ingestion of water
hemlock; confusion
of the root of water
hemlock with wild
parsnip, sweet potato,
or carrot
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
37
Etiologic agent or
cause
Incubation
period (latency)
Exoneurotoxins
A, B, E and F
from Clostridium
botulinum. The
spores are found
in soil and animal
intestines
Mercury poisoning
Chemical agents
Ethyl and methyl
compounds
of mercury in
industrial waste and
organic mercury in
fungicides
4.4 Incubation period higher than 72 hours
Botulism
Bacterial agents
1 week or more
From 2 hours to 8
days, average from
18 to 36 hours
4.3 Incubation period usually from 12 to 72 hours
Disease
Numbness,
weakness of the legs,
spastic paralysis,
deterioration in the
vision, blindness,
coma
Vertigo, double
or blurred vision,
dryness of the
mouth, difficulty in
swallowing, speaking
and breathing;
descending
flaccid paralysis,
constipation,
dilation or fixation
of the pupils,
respiratory paralysis.
Gastrointestinal
symptoms can
precede neurological
symptoms. Is
frequently fatal
Signs and
symptoms
Grains treated
with fungicides
that contain
mercury; pork,
fish, and shellfish
exposed to mercury
compounds
Home-canned
foods with low
acid content,
vacuum-packed
fish; fermented roe,
fish and marine
mammals, fish that
have not been
gutted
Food implicated
Urine, blood, hair
Blood, stool,
gastric lavage
Specimens to
be obtained
Fish caught in waters
contaminated with
mercury compounds,
animals fed with grains
treated with fungicides
containing mercury,
ingestion of mercury,
ingestion of grains
treated with mercury or
meat from animals fed
with those grains
Improper preparation
of canned food
and smoked fish,
uncontrolled
fermentation
Contributing factors
38
Burden of foodborne diseases in the South-East Asia Region
Triorthocresyl
phosphate used
as an extract or
as a substitute for
kitchen oil
Etiologic agent or
cause
From 5 to 21 days,
average 10 days
Incubation
period (latency)
Gastrointestinal
symptoms, pains
in the legs, very
accentuated equine
gait, limpness of feet
and wrist
Signs and
symptoms
Cooking oils,
extracts and
other foodstuffs
contaminated
with triorthocresyl
phosphate
Food implicated
Vibrio vulnificus
Bacillus anthracis
Streptococcus suis
Infection caused by
Vibrio vulnificus
Anthrax
Streptococcus suis
infection
Bacterial agents
5.1 Incubation period between 12-72 hours
Gastroenteritis,
vomiting,
haemorrhagic
depositions
Headache, fever,
vomiting, meningitis,
septicaemia,
endocarditis, toxic
shock syndrome,
arthritis, acute
deafness
3 hours to 14 days
Septicaemia, fever,
malaise, prostration,
typical of cases
with previous liver
problems
From 3 to 5 days
16 hours
CSF or blood
samples
Stool, vomiting
Meat from sick
animals
Infected pigs or
contaminated pork
Blood
Biopsy of the
gastronemius
muscle
Specimens to
be obtained
Oysters and raw
clams
5. Manifestation of signs and symptoms of generalized infection (fever, chills, discomfort, pains)
Triorthocresyl
phosphate poisoning
Disease
Direct contact with
infected or contaminated
materials, processing or
consuming uncooked
or partially cooked pork
products
Clinical manifestations
after consumption of
meat from sick animals
People with liver
problems
Use of the compound
as an extract or as oil for
cooking or for salads
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
39
Etiologic agent or
cause
Listeria
monocytogenes
S. enterica Serotype
typhi found in
faeces of infected
people, other
serotypes (as
paratyphi A, cholera
suis) for cases of
paratyphoid, faeces
of humans and
animals
Typhoid and
paratyphoid fever
Mycobacterium
bovis
Tuberculosis
Listeria infection
Brucella abortus, B.
melitensis, and B.
suis in tissues and
milk of infected
animals
Brucellosis
Bacterial agents
5.2 Incubation period longer than 1 week
Disease
From 7 to 28 days,
average 14 days
3 to 70 days,
usually 4 to 21
days
4–12 weeks
From 7 to 21 days
Incubation
period (latency)
Malaise, headache,
fever, cough,
nausea, vomiting,
constipation,
abdominal pains,
chills, rose spots,
bloody stool
Fever, headache,
nausea, vomiting,
abortion, meningitis,
encephalitis, and
sepsis
Lung lesions
basically but also in
kidneys, liver, spleen
and corresponding
nodes
Fever, chills, sweats,
weakness, malaise,
headache, myalgia
and arthralgia,
weight loss
Signs and
symptoms
Shellfish, food
contaminated by
handlers, raw milk,
cheese, watercress,
water
Milk, fresh cheese,
processed meats
Raw milk and meat
Raw milk, goat
cheese made with
raw milk
Food implicated
Stool, rectal
swabs, blood
in early part of
the acute phase,
urine in the acute
phase
Blood, urine
Culture from
secretions or
tissues
Blood
Specimens to
be obtained
Infected handlers
touching food, poor
personal hygiene,
improper cooking,
inadequate refrigeration,
improper wastewater
disposal, acquisition of
food from contaminated
sources, harvesting of
shellfish from waters
contaminated with
sewage
Improper cooking, nonpasteurization of milk,
prolonged cooling
Consumption of raw
milk, consumption of
raw infected meat from
domestic or wild animals
Unpasteurized milk,
livestock infected by
brucellosis, contact with
aborted materials
Contributing factors
40
Burden of foodborne diseases in the South-East Asia Region
Hepatitis E virus
Hepatitis E
Angiosgtrongylus
cantonensis (lungworm of rats) found
in rodent droppings
and the soil
Toxoplasma gondii
found in tissues and
meat of infected
animals
Angiostrongyliasis (Eosinophilic
meningoencephalitis)
Toxoplasmosis
Parasitic agents
Hepatitis A virus
found in the faeces,
urine, or blood of
infected people and
other infected nonhuman primates
Etiologic agent or
cause
Hepatitis A
Viral agents
Disease
From 10 to 13
days
From 14 to 16
days
From 15 to 65
days usually 35
to 40
From 10 to 50
days, average 25
days
Incubation
period (latency)
Fever, headache,
myalgia, cutaneous
rash
Raw or
undercooked meat
Crabs, prawns,
slugs, shrimp, raw
snails
Shellfish, any food
contaminated with
hepatitis virus,
water
Similar to above
(high mortality for
pregnant women)
Gastroenteritis,
headache, stiffness
of the neck and
back, low-grade
fever
Shellfish, any food
contaminated with
hepatitis virus,
water
Food implicated
Fever, malaise,
lassitude, anorexia,
nausea, abdominal
pains, jaundice
Signs and
symptoms
Lymph nodes (for
biopsy), blood
Blood
Stool, urine,
blood
Stool, urine,
blood
Specimens to
be obtained
Improper cooking of
mutton, pork, beef or
veal
Improper cooking
Infected handlers
touching food, poor
personal hygiene,
improper cooking,
harvesting shellfish from
waters contaminated
with sewage, improper
disposal of waste water
Infected handlers
touching food, poor
personal hygiene,
improper cooking,
harvesting shellfish from
waters contaminated
with sewage, improper
disposal of wastewater
Contributing factors
Burden of foodborne diseases in the South-East Asia Region
41
Trichinella
spiralis found in
pork and bear meat
Etiologic agent or
cause
From 4 to 28 days,
average 9 days
Incubation
period (latency)
Excessive quantity
of monosodium
glutamate
Sodium nicotinate
used as colour
preservative
Nicotinic acid
poisoning (niacin)
Histaminelike substances
produced
by Proteus spp.
or other histidine
bacteria found in
the flesh of fish
Monosodium glutamate
poisoning
Chemical agents
Scombroid poisoning
(Histamine Poisoning)
Bacterial agents (and animals)
Incubation period less than 1 hour
Food implicated
Meat or other food
to which sodium
nicotinate has been
added
Burning sensation in Food seasoned
the back of the neck, with monosodium
forearms and chest;
glutamate
tightness, tingling,
facial flushing,
dizziness, headache,
nausea
Headache, dizziness, Tuna fish, blue
mackerel, Pacific
nausea, vomiting,
peppery taste,
dolphin, cheese
burning in the
throat, facial swelling
and flushing, colic,
itching
Gastroenteritis, fever, Pork, bear, walrus
oedema around the
eyes, myalgia, chills,
prostration, difficulty
breathing
Signs and
symptoms
From a few
Reddening, hot
minutes to an hour flashes, itching,
abdominal pains,
swelling of the face
and knees
From a few
minutes to 1 hour
From a few
minutes to 1 hour
6. Allergic symptoms and signs (flushing and itching of the face)
Trichinosis
Disease
Vomit
Muscle tissue (for
biopsy)
Specimens to
be obtained
Use of sodium nicotinate
to preserve colour
Use of excessive
quantities of
monosodium glutamate
to enhance flavour. Only
some individuals are
sensitive to the MSG
Inadequate refrigeration
of scombroid fish,
improper curing of
cheese
Ingestion of
undercooked pork or
bear meat, improper
cooking or temperatures,
feeding pigs with
garbage that has not
been cooked or properly
treated with heat
Contributing factors
Annex 2
A guide to national burden of foodborne disease study
The FERG’s report on the global burden of foodborne diseases highlights the worldwide
threat of FBDs and emphasizes the need for all national governments, the food industry
and individuals to work together to make food safe and prevent FBDs. The report also
highlights that action to reduce the impact, illnesses and deaths due to FBDs needs to
be adapted based on national needs as the types of food contaminants and reasons
for their prevalence differ in various regions and countries.
While there is no single, global solution to the problem of FBDs, a strengthened
food safety system in one country is likely to positively impact the food safety in other
countries. There is need for coordinated action across the entire food supply chain in
all countries. WHO is working with national governments to improve surveillance of
FBDs to obtain a clear picture of unique local challenges in all countries.
The objectives of individual country studies are to:
••
deliver burden of disease estimates in the area of FBDs;
••
contribute to strengthening the capacity of countries in conducting burden
of foodborne disease assessments, including knowledge translation capacity
development within the country; and
••
provide results that are translated into food safety policy for the country
involved.
The anticipated uses of the results from the burden of foodborne disease studies
are:
(1) prioritization of food safety as an issue within a country.
(2) prioritization of specific food safety issues within a country.
(3) provision of a baseline against which to evaluate future food safety
interventions,
(4) providing assistance with harmonization of international trade and regulatory
standards,
42
Burden of foodborne diseases in the South-East Asia Region
(5) assessment of equivalence of food safety controls for import and export risk
assessments (e.g. within the context of Codex Alimentarius).
Country studies involve two important parallel activities:
••
The collection and analysis of data on the incidence of health effects caused
by food hazards so that the burden of disease can be aggregated into the
DALY metric using calculation methodology developed by FERG; and
••
A situation analysis/context mapping exercise followed by knowledge
translation, which facilitates the use of burden information to develop food
safety policy in a country.
The following tools and documents, developed by the FERG, shall help national
governments in undertaking the studies to estimate the disease burden of FBDs in
countries.
1.
Online WHO tool
This has been developed to help policy-makers identify the most prevalent FBDs in
their regions based on which they could develop appropriate actions to address them
in their countries. By looking at the burden of foodborne diseases in different regions
of the world, the report may also help countries identify relevant lessons on how to
control certain FBDs. The regional burden shall also help prioritize foodborne risks
in countries of the SEA Region and the need for further national studies needed to
quantify them accurately.
2. Burden of FBDs: appraisal of methodology and development of
protocols; burden of foodborne disease: methodology protocol for
country studies (WHO-FERG project: written by Haagsma JA, Polinder S and
Havelaar AH); August 2011
This document describes a protocol for the measurement of the burden of FBDs and
provides information on DALY calculations. It also provides a detailed description of
how incidence data may be derived from different data sources and underreporting
and under-ascertainment, as sources of uncertainty, are explained in detail. Researchers
aiming to undertake the burden of foodborne disease studies in their countries can use
this protocol developed under the framework of FERG.
Burden of foodborne diseases in the South-East Asia Region
43
3.
FERG priority setting tool (WHO, 2012)
This prioritization tool is intended to assist with the identification of agents relevant to the
national burden of foodborne disease study. Agents that will be addressed by the FERG
in its global and regional burden of foodborne disease studies have been categorized
into two groups: (i) global agents of importance in all countries (should be considered
by all national burden studies), and (ii) local agents, which are of importance in some
specific countries or regions, especially in the case of parasitic hazards.
The tool provides key questions to help countries in determining which foodborne
hazards are relevant for their national burden of FBDs study. The list of local agents
may be complemented by additional local agents not addressed by FERG but which
may still be relevant to the national study.
The list of priority pathogens for a specific national burden of foodborne disease
study consists of all “global” and a selection of the “local” agents addressed by FERG and
possibly complemented with other agents that are of particular relevance to the country.
4.
Data sources checklist (Country Studies Task Force: WHO, 2012)
As a part of the FBDs burden protocol to be used in country studies, this guidance
document provides a checklist for participating countries to take stock of existing data
required for the national study and is intended to be an aid to data gathering. However,
it is neither comprehensive nor exhaustive.
The following information is required for a national FBDs burden study:
(1) Demographic baseline
––
Total population for the selected time period, stratified by age and sex;
––
Total number of pregnant women and the total number of live births,
stillbirths and abortions for the selected time period;
––
Local life expectancy table for the selected time period, stratified by
sex.
(2) Epidemiological data
44
––
Years of life lost (YLL) parameters: disease mortality, stratified by age
and sex;
––
Chemicals and toxins: levels in human samples, stratified by age and
sex.
Burden of foodborne diseases in the South-East Asia Region
(3) Food consumption and contamination data
––
Qualitative and quantitative description of food consumption;
––
Qualitative and quantitative description of food contamination.
This guidance document contains four appendices, which contain additional useful
information for the countries undertaking a national burden of foodborne disease study:
Appendix 1: Task Force data sheets
Each of the three agent-specific task forces has generated a list of specific information
needed for its priority agents and corresponding data sources. These task force data
sheets may guide countries in their data collection process.
Appendix 2: Databases and search engines
Relevant online databases and search engines for scientific and grey literature and
online survey catalogues.
Appendix 3: Food consumption atlas data sources
The data sources, identified by the Source Attribution Task Force, will be used for
the compilation of a global Food Consumption Atlas. These specific data sources can
contribute to the assessment of national food consumption patterns.
Appendix 4: Age groups for estimation of FBDs burden
Where possible, estimates will be made for five-year age groups and separately for
males and females. The recommended age groups presented in this appendix coincide
with the age groups in the Global Burden of Diseases 2010.
5. Situation analysis/knowledge translation/risk communication manual
(FERG, 2013)
This manual addresses the situation analysis/context mapping exercise. The objective
is to provide countries undertaking a national burden of foodborne disease study with
a guide to situation analysis/context mapping and knowledge translation to support
the use of burden of disease information in policy-making.
Burden of foodborne diseases in the South-East Asia Region
45
6. FERG workplan matrix for the Country Study Monitoring Matrix
(WHO, 2013)
This is a matrix to assist the countries to monitor the progress of their studies and is
intended to be customized and adapted based on specific country workplans. The
country study monitoring matrix consists of two main sections: content and process of
the monitoring exercise. The content section consists of five items – activity, specific
tasks, activity leader, timelines and final deliverable/output; and the process section
consists of four items – monitoring lead, dates for monitoring and reporting, target
audience and comments.
7. National Foodborne Burden of Disease Study: final report draft
outline (FERG Country Studies Task Force; WHO, 2013)
This is a draft outline to assist countries to prepare a final report of the country study
to estimate the burden of FBDs.
46
Burden of foodborne diseases in the South-East Asia Region
Annex 3: Categorization of
subgroups under WHO regions
Subregion
WHO Member States
AFR D
Algeria; Angola; Benin; Burkina Faso; Cameroon; Cape Verde; Chad; Comoros;
Equatorial Guinea; Gabon; Gambia; Ghana; Guinea; Guinea-Bissau; Liberia;
Madagascar; Mali; Mauritania; Mauritius; Niger; Nigeria; Sao Tome and Principe;
Senegal; Seychelles; Sierra Leone; Togo.
AFR E
Botswana; Burundi; Central African Republic; Congo; Côte d'Ivoire; Democratic
Republic of the Congo; Eritrea; Ethiopia; Kenya; Lesotho; Malawi; Mozambique;
Namibia; Rwanda; South Africa; Swaziland; Uganda; United Republic of
Tanzania; Zambia; Zimbabwe.
AMR A
Canada; Cuba; United States of America.
AMR B
Antigua and Barbuda; Argentina; Bahamas; Barbados; Belize; Brazil; Chile;
Colombia; Costa Rica; Dominica; Dominican Republic; El Salvador; Grenada;
Guyana; Honduras; Jamaica; Mexico; Panama; Paraguay; Saint Kitts and Nevis;
Saint Lucia; Saint Vincent and the Grenadines; Suriname; Trinidad and Tobago;
Uruguay; Venezuela (Bolivarian Republic of).
AMR D
Bolivia (Plurinational State of); Ecuador; Guatemala; Haiti; Nicaragua; Peru.
EMR B
Bahrain; Iran (Islamic Republic of); Jordan; Kuwait; Lebanon; Libyan Arab
Jamahiriya; Oman; Qatar; Saudi Arabia; Syrian Arab Republic; Tunisia; United
Arab Emirates.
EMR D
Afghanistan; Djibouti; Egypt; Iraq; Morocco; Pakistan; Somalia; South Sudan;
Sudan; Yemen.
EUR A
Andorra; Austria; Belgium; Croatia; Cyprus; Czech Republic; Denmark; Finland;
France; Germany; Greece; Iceland; Ireland; Israel; Italy; Luxembourg; Malta;
Monaco; Netherlands; Norway; Portugal; San Marino; Slovenia; Spain; Sweden;
Switzerland; United Kingdom.
EUR B
Albania; Armenia; Azerbaijan; Bosnia and Herzegovina; Bulgaria; Georgia;
Kyrgyzstan; Montenegro; Poland; Romania; Serbia; Slovakia; Tajikistan; The
Former Yugoslav Republic of Macedonia; Turkey; Turkmenistan; Uzbekistan.
EUR C
Belarus; Estonia; Hungary; Kazakhstan; Latvia; Lithuania; Republic of Moldova;
Russian Federation; Ukraine.
SEAR B
Indonesia; Sri Lanka; Thailand.
SEAR D
Bangladesh; Bhutan; Democratic People's Republic of Korea; India; Maldives;
Myanmar; Nepal; Timor-Leste.
WPR A
Australia; Brunei Darussalam; Japan; New Zealand; Singapore.
WPR B
Cambodia; China; Cook Islands; Fiji; Kiribati; Lao People's Democratic Republic;
Malaysia; Marshall Islands; Micronesia (Federated States of); Mongolia; Nauru;
Niue; Palau; Papua New Guinea; Philippines; Republic of Korea; Samoa;
Solomon Islands; Tonga; Tuvalu; Vanuatu; Viet Nam.
Burden of foodborne diseases in the South-East Asia Region
47
Notes:
(1) The subregions are defined on the basis of child and adult mortality as
described by Ezzati et al.4 Stratum A = very low child and adult mortality;
Stratum B = low child mortality and very low adult mortality; Stratum C =
low child mortality and high adult mortality; Stratum D = high child and
adult mortality; and Stratum E = high child mortality and very high adult
mortality. The use of the term subregion here and throughout the text does
not identify an official grouping of WHO Member States and the subregions
are not related to the six official WHO regions, which are AFR = African
Region; AMR = Region of the Americas; EMR = Eastern Mediterranean
Region; EUR = European Region; SEAR = South-East Asia Region; WPR
= Western Pacific Region.
(2) South Sudan was re-assigned to the WHO African Region in May 2013. As
this study relates to time periods prior to this date, estimates for South Sudan
were included in the WHO Eastern Mediterranean Region.
4 Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ, Comparative Risk Assessment Collabo- rating Group (2002) Selected major risk
factors and global and regional burden of disease. Lancet 360 (9343):1347–1360. PMID: 12423980.
48
Burden of foodborne diseases in the South-East Asia Region
Globally, billions of people are at risk of foodborne diseases (FBDs) and millions
fall ill from these every year. Many die as a result of consuming unsafe food. FBDs
can also affect economic development through the tourism, agricultural and
food export industries. The South-East Asia Region has the second highest
burden of FBDs after the African Region, with more than 150 million cases and
175 000 deaths annually.
The World Health Organization has launched a comprehensive and first of
its kind report to estimate the global and regional burden of FBDs. This report will
support policy-makers in implementing the right strategies to prevent, detect and
manage foodborne risks to improve food safety. It highlights the work of WHO's
Regional Office for South-East Asia with national governments on improving
surveillance of foodborne diseases and meeting unique local challenges.
Burden of
foodborne diseases
in the South-East Asia Region
ISBN 978-92-9022-503-4
World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
www.searo.who.int
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