burden of foodborne diseases - who

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in the South-East Asia Region

foodborne diseasesBurden of

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.

9 789290 225034

ISBN 978-92-9022-503-4

Burden of foodborne diseasesin the South-East Asia Region

© World Health Organization 2016

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Printed in India

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)

iiiBurden of foodborne diseases in the South-East Asia Region

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

Contents

vBurden of foodborne diseases in the South-East Asia Region

Acronyms

CA Codex Alimentarius

DALY disability-adjusted life-year

ETEC enterotoxigenic Escherichia coli

EPEC enteropathogenic 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

NTS non-typhoidal Salmonella enterica

POPs persistent organic pollutants

sp., spp. species (sing. and plural)

WHO World Health Organization

1Burden of foodborne diseases in the South-East Asia Region

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.


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.


Chemicals and toxins in food

Food adulteration and falsification are still a problem in countries of the WHO South-East 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,


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.


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;


• 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:

• 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


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).


Table 1: Hazards and foodborne diseases considered in studies

Hazards Foodborne diseasesDiarrhoeal disease agents

Virus (1) NorovirusBacteria (7) 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 disease agents

Virus (1) Hepatitis virus A (HAV)Bacteria (5) Brucel la sp. , Lister ia monocytogenes ,

Mycobacterium bovis (M. bovis), Salmonella paratyphi A (S. paratyphi A), Salmonella typhi (S. typhi)

Protozoan (1) Toxoplasma gondiiHelminths 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 flukeChemicals 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.


Figure 2: Burden of foodborne illness

1 in 10 people in the world fall ill every year due to eating contaminated food


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.


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.


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

0 5 million 10 million 15 million 20 million 25 million

Salmonella typhi

Ascaris species

Entamoeba histolytica

Hepatitis A virus

Enteropathogenic E. coli

Norovirus

Non-typhoidal S. enterica

Enterotoxigenic E. coli

Shigella species

Campylobacter species



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

0 5 000 10 000 15 000 20 000 25 000 30 000 35 000

Campylobacter spp.

Taenia solium

Salmonella paratyphi A

Vibrio cholerae




Hepatitis A virus

Norovirus

Salmonella typhi


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.


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

0 0.5 million 1 million 1.5 million 2 million 2.5 million


Vibrio cholerae

Campylobacter spp.

Taenia solium


Hepatitis A virus



Norovirus

Salmonella typhi


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.


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


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

0 2 million 4 million 6 million 8 million 10 million 12 million

Entamoeba histolytica

Hepatitis A virus

Giardia spp.

Ascaris spp.


Norovirus

Shigella spp.

Campylobacter spp.




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.


Figure 8: Top 10 causes of deaths due to foodborne illnesses in children under five years of age in the South-East Asia Region

0 1 000 2 000 3 000 4 000 5 000 6 000 7 000 8 000

Taenia solium


Shigella spp.

Hepatitis A virus

Campylobacter spp.



Norovirus

Salmonella typhi


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

0 100 000 200 000 300 000 400 000 500 000 600 000 700 000 800 000

Ascaris spp.

Dioxin

Shigella spp.

Hepatitis A virus

Campylobacter spp.



Norovirus

Salmonella typhi


Source: FERG report (2015)


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).


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 policy-makers 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


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


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.


(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

– use safe drinking water for food preparation.

– check use-by dates and labels while buying packed food.


Anne

x 1

Cla

ssifi

catio

n of

food

born

e di

seas

es1

Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

1. In

itial

or m

ajor

sig

ns a

nd s

ympt

oms

of th

e up

per d

iges

tive

trac

ts (n

ause

a, v

omiti

ng)

1.1

Incu

batio

n pe

riod

tend

s to

be

less

than

1 h

our

Fung

al a

gent

s

Poiso

ning

by

mus

hroo

ms o

f the

gr

oup

that

cau

ses

gastr

oint

estin

al ir

ritat

ion

Poss

ibly

resin

-type

su

bsta

nces

foun

d in

som

e ty

pes o

f m

ushr

oom

s

From

30

min

utes

to

2 h

ours

Nau

sea,

vom

iting

, re

tchi

ng, d

iarrh

oea,

ab

dom

inal

pai

ns

Man

y va

rietie

s of

wild

mus

hroo

ms

Vom

itIn

gesti

on o

f unk

now

n to

xic

varie

ties o

f m

ushr

oom

s, th

roug

h co

nfus

ion

with

oth

er

edib

le v

arie

ties

Chem

ical

age

nts

Antim

ony

poiso

ning

Antim

ony

in

enam

elle

d iro

n ut

ensil

s

From

a fe

w

min

utes

to 1

hou

rVo

miti

ng, a

bdom

inal

pa

ins,

diar

rhoe

aVe

ry a

cid

food

and

be

vera

ges

Vom

it, st

ool a

nd

urin

eU

se o

f ute

nsils

that

co

ntai

n an

timon

y, sto

rage

of v

ery

acid

fo

od in

ena

mel

led

iron

uten

sils

Cadm

ium

poi

soni

ngCa

dmiu

m in

pla

ted

uten

sils

From

15

to 3

0 m

inut

esN

ause

a, v

omiti

ng,

abdo

min

al p

ains

, di

arrh

oea,

shoc

k

Very

aci

d fo

ods

and

drin

ks, c

andi

es

and

othe

r cak

e de

cora

tions

Vom

it, st

ool,

urin

e an

d bl

ood

Use

of u

tens

ils th

at

cont

ain

cadm

ium

, sto

rage

of v

ery

acid

fo

od in

con

tain

ers t

hat

cont

ain

cadm

ium

, in

gesti

on o

f foo

ds th

at

cont

ain

cadm

ium

2

1 Ad

apte

d an

d m

odifi

ed fr

om In

stitu

to P

anam

eric

ano

de P

rote

cció

n de

Alim

ento

s y Z

oono

sis (I

NPP

AZ) –

Pan

Am

eric

an H

ealth

Org

aniz

atio

n W

HO

2

Sam

ples

shou

ld b

e co

llect

ed fr

om a

ny o

f the

liste

d fo

ods t

hat h

ave

been

inge

sted

durin

g th

e in

cuba

tion

perio

d of

the

dise

ase.


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Copp

er p

oiso

ning

Copp

er in

pip

es

and

uten

sils

From

a fe

w

min

utes

to a

few

ho

urs

Met

allic

taste

, na

usea

, vom

iting

(g

reen

vom

it),

abdo

min

al p

ains

, di

arrh

oea

Very

aci

d fo

od a

nd

beve

rage

sVo

mit,

gas

tric

lava

ge, u

rine

and

bloo

d

Stor

age

of v

ery

acid

fo

od in

cop

per u

tens

ils

or u

se o

f cop

per t

ubin

g in

serv

ing

very

aci

d be

vera

ges,

defe

ctiv

e va

lves

on

devi

ces

to p

reve

nt re

flux

(in

disp

ense

rs)

Fluo

ride

poiso

ning

(fl

uoro

sis)

Sodi

um fl

uorid

e in

in

sect

icid

esFr

om a

few

m

inut

es to

2 h

ours

Salty

or s

oapy

ta

ste, n

umbn

ess

in th

e m

outh

, vo

miti

ng, d

iarrh

oea,

ab

dom

inal

pai

ns,

pallo

ur, c

yano

sis,

dila

ted

pupi

ls,

spas

ms,

colla

pse,

sh

ock

Any

acci

dent

ally

co

ntam

inat

ed

food

, par

ticul

arly

dr

y fo

od su

ch a

s po

wde

red

milk

, flo

ur, b

akin

g po

wde

r and

cak

e m

ixes

Vom

it an

d ga

stric

la

vage

sSt

orag

e of

inse

ctic

ides

in

the

sam

e pl

ace

as fo

od,

conf

usio

n of

pes

ticid

es

with

pow

dere

d fo

ods

Lead

poi

soni

ngLe

ad c

onta

ined

in

earth

enw

are

pots,

pe

stici

des,

pain

ts,

plas

ter a

nd p

utty

30 m

inut

es o

r m

ore

Met

allic

taste

, bu

rnin

g in

the

mou

th, a

bdom

inal

pa

ins,

milk

y vo

mit,

bl

ack

stool

or

pres

ence

of b

lood

, ba

d br

eath

, sho

ck,

blue

line

at t

he e

dge

of g

ums (

"lead

line

")

Very

aci

d fo

od

and

beve

rage

s sto

red

in v

esse

ls co

ntai

ning

lead

, an

y ac

cide

ntal

ly

cont

amin

ated

food

Vom

it, g

astri

c la

vage

s, sto

ol,

bloo

d an

d ur

ine

Use

of v

esse

ls co

ntai

ning

le

ad, s

tora

ge o

f ver

y ac

id fo

od in

ves

sels

cont

aini

ng le

ad, s

tora

ge

of p

estic

ides

in th

e sa

me

plac

e as

food

Tin

poiso

ning

Tin

in ti

n ca

nsFr

om 3

0 m

inut

es

to 2

hou

rsSw

ellin

g, n

ause

a,

vom

iting

, abd

omin

al

pain

s, di

arrh

oea,

he

adac

he

Very

aci

d fo

ods a

nd

beve

rage

sVo

miti

ng, s

tool

, ur

ine

and

bloo

dSt

orag

e of

aci

d fo

ods i

n un

lined

tin

cont

aine

rs

Zinc

poi

soni

ngZi

nc in

gal

vani

zed

cont

aine

rsFr

om a

few

m

inut

es to

2 h

ours

Mou

th a

nd

abdo

min

al p

ains

, na

usea

, vom

iting

, di

zzin

ess

Very

aci

d fo

od a

nd

beve

rage

sVo

mit,

gas

tric

lava

ges,

urin

e,

bloo

d an

d sto

ol

Stor

age

of v

ery

acid

food

in

gal

vani

zed

tins


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

1.2

Incu

batio

n pe

riod

of 1

to 6

hou

rs

Bact

eria

l age

nts

Baci

llus c

ereu

s ga

stroe

nter

itis (

type

em

etic

)

Exoe

nter

otox

in o

f B.

cer

eus

From

½ to

5 h

ours

Nau

sea,

vom

iting

, oc

casio

nally

di

arrh

oea

Cook

ed o

r frie

d ric

e an

d pl

ates

of

rice

with

mea

t

Vom

it an

d sto

olSt

orag

e of

coo

ked

food

at

war

m te

mpe

ratu

res,

food

coo

ked

in la

rge

cont

aine

rs, fo

od

prep

ared

seve

ral h

ours

befo

re se

rvin

g

Stap

hylo

cocc

al fo

od

poiso

ning

Exoe

nter

otox

ins

A, B

, C, D

and

E

of S

taph

yloco

ccus

au

reus

. St

aphy

loco

cci f

rom

th

e no

se, s

kin,

and

le

sions

of i

nfec

ted

peop

le a

nd a

nim

als,

and

infe

cted

udd

ers

of c

ows

From

1 to

8 h

ours,

av

erag

e of

2 to

4

hour

s

Nau

sea,

vom

iting

, re

tchi

ng, a

bdom

inal

pa

ins,

diar

rhoe

a,

pros

tratio

n

Ham

, bee

f or

poul

try p

rodu

cts,

crea

m-fi

lled

pastr

ies,

food

mix

es

and

lefto

ver f

ood

Patie

nt: v

omit,

sto

ol, r

ecta

l sw

ab.

Carri

er: n

asal

sw

abs,

swab

s fro

m le

sion,

and

re

ctal

swab

s

Inad

equa

te re

frige

ratio

n,

hand

ler t

ouch

ed c

ooke

d fo

od, p

repa

ratio

n of

fo

od se

vera

l hou

rs be

fore

serv

ing,

ha

ndle

rs w

ith p

urul

ent

infe

ctio

ns, f

ood

kept

at

war

m te

mpe

ratu

res

(bac

teria

l inc

ubat

ion)

, fe

rmen

tatio

n of

food

s ab

norm

ally

low

in a

cids

Chem

ical

age

nts 3

Nitr

ite p

oiso

ning

Nitr

ites o

r nitr

ates

us

ed a

s com

poun

ds

to c

ure

mea

t, or

w

ater

from

shal

low

w

ells

From

1 to

2 h

ours

Nau

sea,

vom

iting

, cy

anos

is, h

eada

che,

di

zzin

ess,

wea

knes

s, lo

ss o

f co

nsci

ousn

ess,

choc

olat

e-co

lour

ed

bloo

d

Cure

d m

eats,

an

y ac

cide

ntal

ly

cont

amin

ated

fo

od a

nd e

xpos

ure

to e

xces

sive

nitri

ficat

ion

Bloo

dU

se o

f exc

essiv

e qu

antit

ies

of n

itrite

s or n

itrat

es to

cu

re fo

od o

r con

ceal

spoi

lage,

con

fusio

n of

ni

trite

s with

com

mon

salt,

an

d ot

her c

ondi

men

ts,

inad

equa

te re

frige

ratio

n,

exce

ssive

nitr

ifica

tion

in

ferti

lized

food

3 Ca

rbon

mon

oxid

e po

isoni

ng c

an re

sem

ble

som

e of

the

dise

ases

incl

uded

in th

is ca

tego

ry. P

atie

nts w

ho h

ave

been

insid

e a

clos

ed a

utom

obile

with

the

mot

or ru

nnin

g or

who

hav

e be

en in

hea

ted

room

s with

poo

r ve

ntila

tion

are

at ri

sk o

f exp

osur

e to

car

bon

mon

oxid

e.


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Dia

rrhea

l she

llfish

po

isoni

ng (D

SP)

Oka

daic

o ac

id

and

othe

r tox

ins

prod

uced

by

dino

flage

llate

s of

the

Din

ophy

sis sp

p.

From

1/2

to 1

2 ho

urs,

usua

lly 4

ho

urs

Dia

rrhoe

a, n

ause

a,

abdo

min

al p

ains

Mus

sels,

cla

ms,

oyste

rsG

astri

c rin

seSh

ellfi

sh c

augh

t in

wat

er

with

hig

h co

ncen

tratio

n of

Dyn

ophy

sis sp

p.

1.3

Incu

batio

n pe

riod

usua

lly fr

om 7

to 1

2 ho

urs

Fung

al a

gent

s

Poiso

ning

cau

sed

by

mus

hroo

ms o

f the

cy

clop

eptid

e an

d G

irom

itra

grou

ps

Cycl

opep

tides

an

d gy

rom

itrin

e fo

und

in c

erta

in

mus

hroo

ms

From

6 to

24

hour

sAb

dom

inal

pai

ns,

feel

ing

of fu

llnes

s, vo

miti

ng, p

rolo

nged

di

arrh

oea,

loss

of

stre

ngth

, th

irst,

mus

cle

cram

ps, r

apid

an

d w

eak

pulse

, co

llaps

e, ja

undi

ce,

som

nole

nce,

dila

ted

pupi

ls, c

oma,

dea

th

Aman

ita p

hallo

ides

, A.

ver

na, G

aler

ina

autu

mna

lis.

Escu

lent

a gi

rom

itra

(false

col

men

illa)

an

d sim

ilar s

pp. o

f m

ushr

oom

s

Urin

e, b

lood

, vo

mit

Inge

stion

of c

erta

in

spp.

of A

man

ita,

Gal

erin

a an

d G

irom

itra

mus

hroo

ms,

inge

stion

of

unk

now

n va

rietie

s of

mus

hroo

ms,

conf

usio

n of

toxi

c m

ushr

oom

s with

ed

ible

var

ietie

s

Vira

l age

nt

Nor

oviru

s (N

orw

alk-

like

viru

ses)

Nor

oviru

s viru

ses

are

rela

tivel

y sta

ble

in th

e en

viro

nmen

t an

d ca

n su

rviv

e fre

ezin

g an

d he

atin

g to

60°

C

12 to

48

hour

sVo

miti

ng, w

ater

y, no

n-bl

oody

di

arrh

oea

with

ab

dom

inal

cra

mps

, lo

w-g

rade

feve

r, m

yalg

ia, m

alai

se,

head

ache

Cont

amin

ated

food

or

wat

erSt

ool s

peci

men

s ta

ken

with

in

48 to

72

hour

s af

ter o

nset

of

sym

ptom

s

Dire

ct p

erso

n-to

-per

son

spre

ad o

r fae

cally

co

ntam

inat

ed fo

od o

r w

ater

, tou

chin

g su

rface

s or

obj

ects

cont

amin

ated

w

ith n

orov

irus,

noro

viru

ses c

an a

lso

spre

ad v

ia a

dro

plet

ro

ute

from

vom

itus.


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Smal

l rou

nd v

iruse

s, pr

oduc

tive

of

gastr

oent

eriti

s

Incl

udes

ad

enov

irus,

coro

navi

rus,

rota

viru

s, pa

rvov

irus,

and

astro

viru

s

½ to

3 d

ays,

usua

lly 3

6 ho

urs

Nau

sea,

vom

iting

, di

arrh

oea,

ab

dom

inal

pai

n,

mya

lgia

, hea

dach

e,

light

feve

r. D

urat

ion:

36

hou

rs

Shel

lfish

from

co

ntam

inat

ed w

ater

Stoo

l, bl

ood

in a

cute

and

co

nval

esce

nt

phas

es

Infe

cted

peo

ple

who

to

uch

food

read

y fo

r co

nsum

ptio

n, h

arve

st of

shel

lfish

from

co

ntam

inat

ed w

ater

s, im

prop

er d

ispos

al

of w

aste

s, us

e of

co

ntam

inat

ed w

ater

2. M

anife

stat

ion

of p

hary

ngiti

s an

d re

spira

tory

sig

ns a

nd s

ympt

oms

2.1

Incu

batio

n pe

riod

less

than

1 h

our

Chem

ical

age

nts

Calc

ium

chl

orid

e po

isoni

ngFr

eezi

ng m

ixtu

res o

f ca

lciu

m c

hlor

ide

for

freez

ing

dess

erts

A fe

w m

inut

esBu

rnin

g in

the

tong

ue, m

outh

, and

th

roat

, vom

iting

Froz

en d

esse

rtsVo

mit

Cont

amin

atio

n of

po

psic

les d

urin

g fre

ezin

g, p

erm

ittin

g th

e in

trodu

ctio

n of

cal

cium

ch

lorid

e in

the

syru

p

Sodi

um h

ydro

xide

po

isoni

ngSo

dium

hyd

roxi

de

(cau

stic

soda

) in

com

poun

ds u

sed

to w

ash

bottl

es,

dete

rgen

t, dr

ain

clea

ners,

hai

r-re

laxa

nts

A fe

w m

inut

esBu

rnin

g of

the

lips,

mou

th a

nd th

roat

; vo

miti

ng, a

bdom

inal

pa

ins,

diar

rhoe

a

Bottl

ed b

ever

ages

Vom

itIm

prop

er ri

nsin

g of

bo

ttles

was

hed

with

ca

ustic

subs

tanc

es

2.2

Incu

batio

n pe

riod

from

18

to 7

2 ho

urs

Bact

eria

l age

nts

Infe

ctio

ns b

y be

ta-

haem

olyt

ic st

rept

ococ

ciSt

rept

ococ

cus

pyog

enes

of t

he

thro

at a

nd le

sions

of

infe

cted

peo

ple

From

1 to

3 d

ays

Phar

yngi

tis, f

ever

, na

usea

, vom

iting

, rh

inor

rhoe

a,

som

etim

es ra

sh

Raw

milk

, foo

ds

cont

aini

ng e

ggPh

aryn

geal

swab

s, vo

mit

Wor

kers

who

touc

hed

cook

ed fo

od, w

orke

rs w

ith p

urul

ent i

nfec

tions

, in

adeq

uate

refri

gera

tion,

im

prop

er c

ooki

ng o

r re

heat

ing,

pre

para

tion

of fo

od se

vera

l hou

rs be

fore

serv

ing


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

2.3

Incu

batio

n pe

riod

from

3 to

30

days

Rick

ettsi

al a

gent

Q F

ever

Coxi

ella

bur

netii

2-3

wee

ks (3

-30

days

)Ch

ills,

head

ache

, m

alai

se, m

yalg

ia a

nd

swee

ts

Raw

milk

from

in

fect

ed c

attle

or

goat

s, di

rect

con

tact

w

ith c

onta

min

ated

m

ater

ials

Seru

mCo

nsum

ptio

n of

raw

m

ilk, d

irect

con

tact

w

ith a

borte

d m

ater

ials,

in

adeq

uate

disi

nfec

tion

and

disp

osal

of a

borte

d m

ater

ials

3. In

itial

or m

ajor

sig

ns a

nd s

ympt

oms

of th

e lo

wer

dig

estiv

e tr

act (

abdo

min

al p

ains

, dia

rrho

ea)

3.1

Incu

batio

n pe

riod

usua

lly fr

om 7

to 1

2 ho

urs

Bact

eria

l age

nts

Gas

troen

terit

is by

Bac

illus

cer

eus

(dia

rrhea

l typ

e)

Exoe

nter

otox

in o

f B.

cere

us, o

rgan

isms i

n th

e so

il

From

8 to

16

hour

s (av

erag

e of

12

hou

rs)

Nau

sea,

abd

omin

al

pain

s, di

arrh

oea

Food

s mad

e fro

m g

rain

s, ric

e,

custa

rd, s

auce

s, m

eatb

alls,

saus

ages

, co

oked

veg

etab

les,

dehy

drat

ed o

r re

cons

titut

ed

prod

ucts

Stoo

lIn

adeq

uate

refri

gera

tion,

sto

rage

of f

ood

at w

arm

te

mpe

ratu

res (

bact

eria

l in

cuba

tion)

, pre

para

tion

of fo

od se

vera

l hou

rs be

fore

serv

ing,

impr

oper

re

heat

ing

of le

ftove

rs

Gas

troen

terit

is ca

used

by

Clo

strid

ium

pe

rfrin

gens

Endo

ente

roto

xin

form

ed d

urin

g th

e sp

orul

atio

n of

C.

perfr

inge

ns in

the

inte

stine

s, th

e bo

dy, i

n hu

man

or

anim

als f

aece

s or i

n th

e so

il

From

8 to

22

hour

s (av

erag

e of

10

hou

rs)

Abdo

min

al p

ains

, di

arrh

oea

Cook

ed b

eef o

r po

ultry

, bro

ths,

sauc

es a

nd so

ups

Stoo

lIn

adeq

uate

refri

gera

tion,

sto

rage

of f

ood

at w

arm

te

mpe

ratu

res (

bact

eria

l in

cuba

tion)

, pre

para

tion

of fo

od se

vera

l hou

rs be

fore

serv

ing,

impr

oper

re

heat

ing

of le

ftove

r fo

od


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

3.2

Incu

batio

n pe

riod

usua

lly fr

om 1

8 to

72

hour

s

Bact

eria

l age

nts

Dia

rrhea

l dise

ases

ca

used

by

Aero

mon

asAe

rom

onas

hy

drop

hila

1 to

2 d

ays

Wat

ery

diar

rhoe

a,

abdo

min

al p

ain,

na

usea

, hea

dach

e

Fish

, she

llfish

, sn

ails,

wat

erSt

ool

Cont

amin

atio

n of

food

in

sea

or su

rface

wat

er

Cam

pylo

bact

er

Infe

ctio

nCa

mpy

loba

cter

je

juni

2 to

7 d

ays u

sual

ly

betw

een

3 an

d 5

Abdo

min

al p

ains

, di

arrh

oea

(freq

uent

ly

with

muc

us a

nd

bloo

d), h

eada

che,

m

yalg

ia, f

ever

, an

orex

ia, n

ause

a,

vom

iting

. Seq

uella

e:

Gui

llian

-Bar

re

synd

rom

e

Raw

milk

, bee

f liv

er, r

aw c

lam

s St

ool o

r rec

tal

swab

s, bl

ood

Drin

king

raw

milk

, ha

ndlin

g ra

w p

rodu

cts,

eatin

g ra

w o

r un

derc

ooke

d po

ultry

, in

adeq

uate

coo

king

or

paste

uriz

atio

n, c

ross

-co

ntam

inat

ion

with

raw

m

eat

Chol

era

Endo

ente

roto

xin

of

V. c

hole

rae

clas

sical

an

d El

Tor

bio

type

s, fro

m fa

eces

of

infe

cted

per

sons

From

1 to

3 d

ays

Seve

re, w

ater

y di

arrh

oea

(rice

wat

er

stool

s), v

omiti

ng,

abdo

min

al p

ains

, de

hydr

atio

n, th

irst,

colla

pse,

loss

of

skin

tone

, shr

ivel

led

finge

rs, su

nken

eye

s

Raw

fish

and

sh

ellfi

sh, f

ood

was

hed

or

prep

ared

with

co

ntam

inat

ed

wat

er, w

ater

Stoo

lH

arve

sting

of f

ish a

nd

shel

lfish

from

wat

er

cont

amin

ated

with

se

wag

e in

end

emic

ar

eas,

poor

per

sona

l hy

gien

e, in

fect

ed

hand

lers

who

touc

hed

food

, ina

dequ

ate

cook

ing,

use

of

cont

amin

ated

wat

er in

w

ashi

ng o

r rin

sing

food

, im

prop

er d

ispos

al o

f w

aste

wat

er, u

se o

f was

te

from

latri

nes a

s fer

tiliz

er


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Gas

troen

terit

is ca

used

by

cho

lera

like

vib

rioCh

oler

a lik

e vib

rioFr

om 5

to 4

8 ho

urs,

aver

age

from

10

to 2

4 ho

urs

Abdo

min

al p

ains

, di

arrh

oea,

nau

sea,

vo

miti

ng, f

ever

, ch

ills,

head

ache

, m

yalg

ia

Vario

us fo

ods,

wat

erSt

ool,

rect

al

swab

sIn

fect

ed h

andl

ers w

ho

touc

h fo

od, i

nsuf

ficie

nt

cool

ing,

inco

mpl

ete

cook

ing,

impr

oper

cl

eani

ng a

nd d

isinf

ectio

n of

equ

ipm

ent

Dia

rrhoe

al

dise

ases

cau

sed

by

Ente

roha

emor

rhag

ic

Esch

eric

hia

coli

E. c

oli O

157:

H7,

O

26, O

111,

O11

5,

O11

3

1 to

10

days

us

ually

2 to

5 d

ays

Wat

ery

diar

rhoe

a fo

llow

ed b

y bl

oody

di

arrh

oea,

seve

re

abdo

min

al p

ain,

bl

ood

in th

e ur

ine.

Seq

uela

e:

Hae

mol

ytic

ure

mic

sy

ndro

me

(HU

S)

Ham

burg

er, r

aw

milk

, sau

sage

s, yo

gurt,

lettu

ce,

wat

er

Stoo

l, re

ctal

sw

abs

Ham

burg

er m

ade

from

mea

t of i

nfec

ted

anim

als,

cons

umpt

ion

of ra

w m

eat a

nd m

ilk,

inad

equa

te c

ooki

ng,

cros

s-co

ntam

inat

ion,

in

fect

ed p

eopl

e to

uchi

ng fo

od re

ady

for

cons

umpt

ion,

impr

oper

de

sicca

tion

and

ferm

enta

tion

of m

eats

Dia

rrhoe

a ca

used

by

Ent

eroi

nvas

ive

Esch

eric

hia

coli

Stra

ins o

f En

tero

inva

sive

E. c

oli

½ to

3 d

ays

Seve

re a

bdom

inal

pa

in, f

ever

, wat

ery

diar

rhoe

a, (u

sual

ly

with

muc

us a

nd

bloo

d pr

esen

t) te

nesm

us

Sala

ds a

nd o

ther

fo

od th

at a

re n

ot

subs

eque

ntly

tre

ated

, wat

er

Stoo

l, re

ctal

sw

abs

Inad

equa

te c

ooki

ng,

infe

cted

per

sons

to

uchi

ng fo

od re

ady

for c

onsu

mpt

ion,

not

w

ashi

ng h

ands

afte

r de

feca

tion,

stor

ing

food

at

room

tem

pera

ture

, sto

ring

food

in th

e re

frige

rato

r in

larg

e co

ntai

ners,

pre

parin

g fo

od se

vera

l hou

rs be

fore

serv

ing,

impr

oper

re

heat

ing

of fo

od


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Dia

rrhoe

a ca

used

by

ETEC

St

rain

s of E

TEC

½ to

3 d

ays

Prof

use

wat

ery

diar

rhoe

a (w

ithou

t m

ucus

or b

lood

) ab

dom

inal

pa

in, v

omiti

ng,

pros

tratio

n,

dehy

drat

ion,

ligh

t fe

ver

Sala

ds a

nd o

ther

fo

od th

at a

re n

ot

subs

eque

ntly

th

erm

ally

trea

ted,

fre

sh c

hees

es,

wat

er

Stoo

l, re

ctal

sw

abs

Inad

equa

te c

ooki

ng,

infe

cted

peo

ple

touc

hing

food

read

y fo

r con

sum

ptio

n, n

ot

was

hing

han

ds a

fter

defe

catio

n, st

orag

e of

food

at r

oom

te

mpe

ratu

re, k

eepi

ng

food

in th

e re

frige

rato

r in

larg

e co

ntai

ners,

pr

epar

ing

food

seve

ral

hour

s bef

ore

serv

ing,

im

prop

er re

heat

ing

of

food

, use

of r

aw m

ilk in

m

akin

g ch

eese

Ente

ritis

by P

lesio

mon

asPl

eiso

mon

as

shig

eloi

des

1 to

2 d

ays

Dia

rrhoe

a w

ith

muc

us a

nd b

lood

in

the

stool

Wat

erSt

ool,

rect

al

swab

sIn

adeq

uate

coo

king

Salm

onel

losis

Vario

us se

roty

pes

of S

alm

onel

la fr

om

faec

es o

f inf

ecte

d pe

ople

and

ani

mal

s

From

6 to

72

hour

s, av

erag

e fro

m 1

8 to

36

hour

s

Abdo

min

al p

ains

, di

arrh

oea,

chi

lls,

feve

r, na

usea

, vo

miti

ng, m

alai

se

Beef

and

pou

ltry

and

thei

r by-

prod

ucts,

egg

pr

oduc

ts, o

ther

fo

ods c

onta

min

ated

w

ith sa

lmon

ella

e

Stoo

l, re

ctal

sw

abs

Inad

equa

te re

frige

ratio

n,

stora

ge o

f foo

d at

w

arm

tem

pera

ture

s (b

acte

rial i

ncub

atio

n),

inad

equa

te c

ooki

ng a

nd

rehe

atin

g, p

repa

ratio

n of

food

seve

ral h

ours

befo

re se

rvin

g, c

ross

-co

ntam

inat

ion,

impr

oper

cl

eani

ng o

f equ

ipm

ent,

infe

cted

han

dler

s who

to

uch

cook

ed fo

od,

acqu

isitio

n of

food

from

co

ntam

inat

ed so

urce

s.


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Shig

ello

sisSh

igel

la fl

exne

ri,

S. d

ysen

teria

e, S

. so

nnei

and

S. b

oydi

i

From

½ to

7 d

ays,

usua

lly fr

om 1

to

3 da

ys

Abdo

min

al p

ains

, di

arrh

oea,

muc

oid

faec

es w

ith b

lood

pr

esen

t, fe

ver

Any

food

read

y fo

r con

sum

ptio

n th

at b

ecom

es

cont

amin

ated

, fre

quen

tly sa

lads

, w

ater

Stoo

l, re

ctal

sw

abs

Infe

cted

han

dler

s to

uchi

ng th

e fo

od,

inad

equa

te re

frige

ratio

n,

impr

oper

coo

king

and

re

heat

ing

Gas

troen

terit

is ca

used

by

V. p

arah

aem

olyt

icus

V. p

arah

aem

olyt

icus

fro

m se

a w

ater

or

mar

ine

prod

ucts

From

2 to

48

hour

s, av

erag

e 12

ho

urs

Abdo

min

al p

ains

, di

arrh

oea,

nau

sea,

vo

miti

ng, f

ever

, ch

ills,

head

ache

Raw

or

cont

amin

ated

sea

food

, she

llfish

Stoo

l, re

ctal

sw

abs

Inad

equa

te c

ooki

ng,

inad

equa

te re

frige

ratio

n,

cros

s-co

ntam

inat

ion,

im

prop

er c

lean

ing

of

equi

pmen

t, us

e of

sea

wat

er in

pre

parin

g fo

od

Dia

rrhoe

a ca

used

by

yers

inio

sisYe

rsin

ia

ente

roco

litic

a1

to 7

day

sAb

dom

inal

pai

ns

(can

sim

ulat

e ap

pend

iciti

s), li

ght

feve

r, he

adac

he,

disc

omfo

rt, a

nore

xia,

na

usea

, vom

iting

Raw

milk

, wat

erSt

ool,

rect

al

swab

sIn

adeq

uate

coo

king

or

pas

teur

izat

ion,

cr

oss-

cont

amin

atio

n,

cont

amin

ated

in

gred

ient

s or w

ater

Vira

l age

nts

Vira

l gas

troen

terit

isEn

teric

viru

ses

(ech

oviru

s, co

xsac

kiev

irus,

reov

irus,

aden

oviru

s)

From

3 to

5 d

ays

Dia

rrhoe

a, fe

ver,

vom

iting

, abd

omin

al

pain

s, so

met

imes

re

spira

tory

sy

mpt

oms

Food

read

y fo

r co

nsum

ptio

nSt

ool

Poor

per

sona

l hyg

iene

, in

fect

ed w

orke

rs to

uchi

ng fo

od, i

mpr

oper

co

okin

g an

d re

heat

ing

3.3

Incu

batio

n pe

riod

from

a fe

w d

ays

to s

ever

al w

eeks

Para

sitic

age

nts

Asca

riasis

Asca

ris lu

mbr

icoi

des

14 to

20

days

Stom

ach

diso

rder

s, cr

amps

, vom

iting

, fe

ver

Vege

tabl

es a

nd

wat

erSt

ool

Inad

equa

te w

aste

di

spos

al, p

oor h

ygie

ne in

fo

od h

andl

ing


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Amoe

bic

dyse

nter

y (a

moe

bias

is)En

tam

oeba

hi

stolyt

ica

From

a fe

w d

ays

to se

vera

l mon

ths

usua

lly b

etw

een

2 an

d 4

wee

ks

Abdo

min

al p

ains

, co

nstip

atio

n or

di

arrh

oea

with

blo

od

and

muc

us

Vege

tabl

es a

nd ra

w

fruits

Stoo

lPo

or p

erso

nal h

ygie

ne,

infe

cted

han

dler

s to

uchi

ng th

e fo

od,

impr

oper

coo

king

and

re

heat

ing

Gia

rdia

sisG

iard

ia la

mbl

ia

from

faec

es o

f in

fect

ed p

eopl

e

From

1 to

6 w

eeks

Abdo

min

al p

ains

, di

arrh

oea

with

m

ucus

, fat

ty st

ools

Raw

frui

ts an

d ve

geta

bles

, wat

erSt

ool

Poor

per

sona

l hyg

iene

, in

fect

ed h

andl

ers

touc

hing

food

, im

prop

er

cook

ing,

impr

oper

was

te

wat

er d

ispos

al

Cryp

tosp

orid

iosis

Cryp

tosp

orid

ium

pa

rvum

1 to

12

days

, us

ually

7 d

ays

Prof

use

wat

ery

diar

rhoe

a,

abdo

min

al p

ain,

an

orex

ia, v

omiti

ng,

light

feve

r

Appl

e ci

der,

wat

erSt

ool,

inte

stina

l bi

opsy

Impr

oper

disp

osal

of

ani

mal

was

tes,

cont

amin

atio

n fro

m th

e an

imal

env

ironm

ent,

inad

equa

te fi

lterin

g of

w

ater

Hyd

atid

osis

(uni

locu

lar

or m

ultil

ocul

ar)

Echi

noco

ccus

gr

anul

osus

, Ec

hino

cocc

us

mul

tiloc

ular

is

Mon

ths t

o ye

ars

Abdo

min

al p

ain,

ab

norm

al a

bdom

inal

te

nder

ness

, he

pato

meg

aly

with

an

abd

omin

al m

ass,

jaun

dice

, fev

er

Food

or w

ater

co

ntam

inat

ed w

ith

faec

es o

f inf

ecte

d do

g, fo

x

Biop

sy o

r ser

umCo

nsum

ptio

n of

raw

ve

geta

bles

or w

ater

co

ntam

inat

ed w

ith

faec

es o

f inf

ecte

d do

g or

fox

Live

rfluk

e (F

asci

olia

sis)

Fasc

iola

hep

atic

aFr

om 4

to 6

wee

ksD

yspe

psia

, fev

er,

right

upp

er q

uadr

ant

pain

, ano

rexi

a,

hepa

tom

egal

y, sp

leno

meg

aly,

asci

tes,

urtic

aria

, re

spira

tory

sy

mpt

oms,

and

jaun

dice

Aqua

tic p

lant

s or

plan

ts w

ith h

igh

moi

sture

con

tent

Stoo

l, tis

sue

biop

syEa

ting

raw

aqu

atic

pl

ants,

inef

ficie

nt

disp

osal

of h

uman

and

an

imal

was

tes i

n po

nd o

r w

ater

bod

ies


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Opi

sthor

chia

sisO

. vive

rrine

, O.

felin

eus

From

4 to

5 w

eeks

Flat

ulen

ce, f

atig

ue,

dysp

epsia

, rig

ht

uppe

r qua

dran

t ab

dom

inal

pai

n,

anor

exia

, and

mild

he

pato

meg

aly

raw

or

unde

rcoo

ked

fish

Stoo

lCo

nsum

ing

raw

or

unde

rcoo

ked

fish

and

impr

oper

sani

tary

di

spos

al o

f fae

ces

faci

litat

e in

festa

tion

of

fish

in p

onds

Inte

stina

l flu

ke

(Fas

ciol

opsis

)Fa

scio

lops

is bu

ksi,

Echi

nosto

ma

6–8

wee

ksD

iarrh

oea,

co

nstip

atio

n,

abdo

min

al

pain

, diz

zine

ss,

and

head

ache

, so

met

imes

vom

iting

, fe

ver,

naus

ea, a

nd

alle

rgic

reac

tions

su

ch a

s oed

ema

of

the

face

Raw

or

unde

rcoo

ked

aqua

tic p

lant

s

Stoo

lCo

nsum

ing

raw

aq

uatic

pla

nts,

faec

al

cont

amin

atio

n (fr

om

hum

ans o

r pig

s) of

wat

er

whe

re a

quat

ic p

lant

s are

gr

own

Lung

fluk

e (P

arag

onim

iasis

)Pa

rago

nim

us

wes

term

ani

2–15

day

sCo

ugh,

feve

r, bl

oody

sp

utum

, los

s of

appe

tite,

che

st pa

in,

and

head

ache

Ch

roni

c sta

ge:

prod

uctiv

e co

ugh

with

bro

wni

sh

sput

um, c

hest

pain

, an

d ni

ght s

wea

ts

Raw

or

unde

rcoo

ked

crab

or

cra

yfish

Sput

um, s

tool

Crab

or c

rayf

ish

cons

umed

raw

or

prep

ared

onl

y in

vin

egar

, br

ine,

or w

ine

with

out

cook

ing

Taen

iasis

due

to Ta

enia

so

lium

(por

k ta

pew

orm

)T.

soliu

m fr

om

infe

cted

por

kFr

om 3

to 6

wee

ksG

ener

al m

alai

se,

hung

er, w

eigh

t los

sRa

w o

r un

derc

ooke

d po

rkSt

ool

Failu

re to

insp

ect m

eat,

impr

oper

coo

king

, im

prop

er w

aste

wat

er

disp

osal

, gra

sses

co

ntam

inat

ed b

y w

aste

w

ater


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Taen

iasis

due

to

Taen

ia sa

gina

ta (b

eef

tape

wor

m)

T. sa

gina

ta fr

om

mea

t fro

m m

eat o

f in

fect

ed c

attle

From

8 to

14

wee

ksG

ener

al m

alai

se,

hung

er, w

eigh

t los

s, ab

dom

inal

pai

ns

Raw

or

unde

rcoo

ked

mea

tSt

ool

Failu

re to

insp

ect m

eat,

impr

oper

coo

king

, im

prop

er w

aste

wat

er

disp

osal

, pas

ture

co

ntam

inat

ed b

y w

aste

w

ater

Anisa

kias

isAn

isaki

s ps

eudo

terra

nova

From

4 to

6 w

eeks

Stom

ach

pain

, na

usea

, vom

iting

, ab

dom

inal

pai

n

Rock

fish

, her

ring,

co

d, sa

lmon

, squ

id,

sush

i

Stoo

lIn

gesti

on o

f raw

or

unde

rcoo

ked

fish

Dip

hyllo

botri

asis

(fish

ta

pew

orm

infe

ctio

n)D

iphy

llobo

thriu

m

latu

m fr

om fl

esh

of

infe

cted

fish

From

3 to

6 w

eeks

Und

efin

ed

gastr

oint

estin

al

disc

omfo

rt, a

naem

ia

may

occ

ur

Raw

or

unde

rcoo

ked

fresh

w

ater

fish

Stoo

lIn

adeq

uate

coo

king

, im

prop

er w

aste

wat

er

disp

osal

, lak

es

cont

amin

ated

by

was

te

wat

er

Spar

gano

sisSp

irom

etra

spp.

pain

ful o

edem

a,

seiz

ures

, he

mip

ares

is, a

nd

head

ache

s

Cont

amin

ated

w

ater

, con

sum

ing

raw

fles

h of

frog

or

snak

e

Biop

syD

rinki

ng w

ater

co

ntam

inat

ed w

ith

infe

cted

cop

epod

s or

con

sum

ing

raw

or

unde

r-coo

ked

flesh

of

frog

or sn

ake

4. M

anife

stat

ion

of n

euro

logi

cal s

igns

and

sym

ptom

s (v

isua

l dis

orde

rs, t

ingl

ing,

par

alys

is)

4.1

Incu

batio

n pe

riod

tend

s to

be

less

than

1 h

our

Fung

al a

gent

s

Mus

hroo

m p

oiso

ning

fro

m th

e gr

oup

that

co

ntai

ns ib

oten

ic a

cid

Ibot

enic

and

m

usci

mol

foun

d in

ce

rtain

mus

hroo

ms

From

30

to 6

0 m

inut

esSo

mno

lenc

e an

d sta

te o

f int

oxic

atio

n,

conf

usio

n, m

uscu

lar

spas

ms,

delir

ium

, vi

sual

diso

rder

s

Aman

ita

mus

caria

, A.

pant

herin

a, a

nd

rela

ted

spp.

of

mus

hroo

ms

In

gesti

on o

f Am

anita

m

usca

ria a

nd re

late

d sp

p. o

f mus

hroo

ms,

inge

stion

of u

nkno

wn

varie

ties o

f mus

hroo

ms,

conf

usio

n of

toxi

c m

ushr

oom

s with

edi

ble

varie

ties


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Poiso

ning

cau

sed

by m

ushr

oom

s of

the

grou

p th

at

cont

ains

mus

carin

e (m

usca

rinism

)

Mus

carin

e fo

und

in

certa

in m

ushr

oom

s15

min

utes

to a

fe

w h

ours

Exce

ssiv

e sa

liva-

tion,

per

spira

tion,

la

crim

atio

n, d

rop

in b

lood

pre

ssur

e,

irreg

ular

pul

se,

cont

ract

ion

of th

e pu

pils,

blu

rred

visio

n, a

sthm

atic

br

eath

ing

Clito

cybe

dea

l-ba

ta, C

. riv

ulos

e,

and

man

y sp

p. o

f In

ocyb

e an

d Bo

le-

tus m

ushr

oom

s

Vom

itIn

gesti

on o

f A.

mus

caria

and

rela

ted

spp.

, con

sum

ptio

n of

unk

now

n va

rietie

s of

mus

hroo

ms,

cons

umpt

ion

of to

xic

mus

hroo

ms b

y m

istak

e

Chem

ical

age

nts

Org

anop

hosp

horu

s po

isoni

ngO

rgan

opho

spho

rus

inse

ctic

ides

, suc

h as

par

athi

on, T

EPP,

diaz

inon

, mal

athi

on

From

a fe

w

min

utes

to a

few

ho

urs

Nau

sea,

vom

iting

, ab

dom

inal

pa

ins,

diar

rhoe

a,

head

ache

, ne

rvou

snes

s, bl

urre

d vi

sion,

che

st pa

ins,

cyan

osis,

con

fusio

n,

spas

mod

ic

cont

ract

ion,

co

nvul

sions

Any

acci

dent

ally

co

ntam

inat

ed fo

odBl

ood,

urin

e,

adip

ose

tissu

e (fo

r bi

opsy

)

Spra

ying

of c

rops

im

med

iate

ly b

efor

e ha

rves

t, sto

rage

of

inse

ctic

ides

in th

e sa

me

plac

e as

food

, con

fusio

n of

pes

ticid

es w

ith fo

od in

po

wde

red

form

Carb

amat

e po

isoni

ngCa

rbar

yl (s

evin

), Te

mik

(ald

icar

b)½

hou

rEp

igas

tric

pain

, vo

miti

ng, a

bnor

mal

sa

livat

ion,

co

ntra

ctio

n of

th

e pu

pils,

lack

of

mus

cula

r co

ordi

natio

n

Any

acci

dent

ally

co

ntam

inat

ed fo

odBl

ood,

urin

eIm

prop

er a

pplic

atio

n to

cro

ps, s

tora

ge in

the

sam

e ar

eas a

s foo

d,

mist

aken

as f

ood

in

pow

dere

d fo

rm


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Din

ofla

gella

tes

Para

lytic

She

llfish

Po

isoni

ngSa

xito

xin

and

othe

r din

ofla

gella

te

toxi

ns o

f the

spp.

Al

exan

driu

m a

nd

Gym

nodi

nium

Seve

ral m

inut

es to

30

min

utes

Ting

ling,

bur

ning

, an

d nu

mbn

ess

arou

nd th

e lip

s an

d th

e tip

s of t

he

finge

rs, d

izzy

spel

ls,

inco

here

nt sp

eech

, re

spira

tory

par

alys

is

Mus

sels

and

clam

sG

astri

c la

vage

Har

vesti

ng sh

ellfi

sh

from

wat

er w

ith h

igh

conc

entra

tions

of

dino

flage

llate

s of t

he

spp.

Ale

xand

rium

and

G

ymno

dini

um

Tetro

doto

xism

(te

traod

on p

oiso

ning

)Te

trodo

xin

foun

d in

th

e in

testi

nes a

nd

gona

ds o

f puf

fer f

ish

(blo

wfis

h, g

lobe

fish)

From

10

min

utes

to

3 h

ours

Sens

atio

n of

tin

glin

g in

the

finge

rs an

d to

es,

dizz

ines

s, pa

llor,

num

bnes

s of t

he

mou

th a

nd li

mbs

, ga

stroi

ntes

tinal

sy

mpt

oms,

haem

orrh

age

and

flaki

ng o

f the

skin

, fix

atio

n of

the

eyes

, spa

smod

ic

cont

ract

ion,

pa

raly

sis, c

yano

sis

Fish

of t

he p

uffe

r fis

h fa

mily

Sto

olIn

gesti

on o

f fish

of

the

puffe

r fish

fam

ily,

cons

umpt

ion

of su

ch

fish

with

out e

xtra

ctin

g in

testi

nes a

nd g

onad

s

Poiso

nous

pla

nts

Jimso

nwee

d (th

orn

appl

e) p

oiso

ning

Trop

ane

alka

loid

s fo

und

in D

atur

a str

amon

ium

Less

than

1 h

our

Abno

rmal

thirs

t, ph

otop

hobi

a,

disto

rted

visio

n,

diffi

culty

spea

king

, de

liriu

m, f

acia

l flu

shin

g, d

eliri

um,

com

a, ra

pid

pulse

he

art a

ttack

.

Any

part

of th

e he

rb, t

omat

oes

grow

n w

ith g

rafts

Urin

eCo

nsum

ptio

n of

any

pa

rt of

the

Jimso

n w

eed

or c

onsu

mpt

ion

of

tom

atoe

s gro

wn

with

gr

afts


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Wat

er h

emlo

ck

poiso

ning

Resin

or c

icut

oxin

fo

und

in w

ater

he

mlo

ck

From

15

to 6

0 m

inut

esEx

cess

ive

saliv

atio

n,

naus

ea, v

omiti

ng,

stom

ach

pain

s, fro

thin

g at

the

mou

th, i

rregu

lar

brea

thin

g,

conv

ulsio

ns,

resp

irato

ry p

aral

ysis

Root

of w

ater

he

mlo

ck (C

icut

a vi

rosa

and

C.

mas

cula

ta)

Urin

eIn

gesti

on o

f wat

er

hem

lock

; con

fusio

n of

the

root

of w

ater

he

mlo

ck w

ith w

ild

parsn

ip, s

wee

t pot

ato,

or

car

rot

4.2

Incu

batio

n pe

riod

usua

lly b

etw

een

1 an

d 6

hour

s

Chem

ical

age

nts

Chlo

rinat

ed

hydr

ocar

bon

poiso

ning

Inse

ctic

ides

co

ntai

ning

ch

lorin

ated

hy

droc

arbo

n, su

ch

as a

ldrin

, chl

orda

ne,

DD

T, d

ield

rin,

endr

in, l

inda

ne,

and

toxa

phen

e

From

30

min

utes

to

6 h

ours

Nau

sea,

vom

iting

, pa

resth

esia

, di

zzin

ess,

mus

cula

r w

eakn

ess,

anor

exia

, w

eigh

t los

s, co

nfus

ion

Any

acci

dent

ally

co

ntam

inat

ed fo

odBl

ood,

urin

e,

stool

, gas

tric

lava

ges

Stor

age

of in

sect

icid

es in

th

e sa

me

plac

e as

food

, co

nfus

ion

of p

estic

ides

w

ith fo

od in

pow

dere

d fo

rm

Mar

ine

plan

kton

Cigu

ater

a po

isoni

ngCi

guat

oxin

from

th

e in

testi

nes,

roe,

go

nads

, and

fles

h of

tro

pica

l mar

ine

fish

From

3 to

5 h

ours,

so

met

imes

mor

eTi

nglin

g an

d nu

mbn

ess a

roun

d th

e m

outh

, met

allic

ta

ste, d

ryne

ss

of th

e m

outh

, ga

stroi

ntes

tinal

sy

mpt

oms,

wat

ery

stool

, mya

lgia

, di

zzin

ess,

dila

ted

pupi

ls, b

lurre

d vi

sion,

pro

strat

ion,

pa

raly

sis

Num

erou

s var

ietie

s of

trop

ical

fish

In

gesti

on o

f liv

er,

inte

stine

s, ro

e, g

onad

s, or

fles

h of

trop

ical

reef

fis

h; in

gen

eral

the

larg

e re

ef fi

sh a

re m

ore

likel

y to

be

toxi

c


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

4.3

Incu

batio

n pe

riod

usua

lly fr

om 1

2 to

72

hour

s

Bact

eria

l age

nts

Botu

lism

Exon

euro

toxi

ns

A, B

, E a

nd F

fro

m C

lostr

idiu

m

botu

linum

. The

sp

ores

are

foun

d in

soil

and

anim

al

inte

stine

s

From

2 h

ours

to 8

da

ys, a

vera

ge fr

om

18 to

36

hour

s

Verti

go, d

oubl

e or

blu

rred

visio

n,

dryn

ess o

f the

m

outh

, diff

icul

ty in

sw

allo

win

g, sp

eaki

ng

and

brea

thin

g;

desc

endi

ng

flacc

id p

aral

ysis,

co

nstip

atio

n,

dila

tion

or fi

xatio

n of

the

pupi

ls,

resp

irato

ry p

aral

ysis.

G

astro

inte

stina

l sy

mpt

oms c

an

prec

ede

neur

olog

ical

sy

mpt

oms.

Is fre

quen

tly fa

tal

Hom

e-ca

nned

fo

ods w

ith lo

w

acid

con

tent

, va

cuum

-pac

ked

fish;

ferm

ente

d ro

e,

fish

and

mar

ine

mam

mal

s, fis

h th

at

have

not

bee

n gu

tted

Bloo

d, st

ool,

gastr

ic la

vage

Impr

oper

pre

para

tion

of c

anne

d fo

od

and

smok

ed fi

sh,

unco

ntro

lled

ferm

enta

tion

4.4

Incu

batio

n pe

riod

high

er th

an 7

2 ho

urs

Chem

ical

age

nts

Mer

cury

poi

soni

ngEt

hyl a

nd m

ethy

l co

mpo

unds

of

mer

cury

in

indu

stria

l was

te a

nd

orga

nic

mer

cury

in

fung

icid

es

1 w

eek

or m

ore

Num

bnes

s, w

eakn

ess o

f the

legs

, sp

astic

par

alys

is,

dete

riora

tion

in th

e vi

sion,

blin

dnes

s, co

ma

Gra

ins t

reat

ed

with

fung

icid

es

that

con

tain

m

ercu

ry; p

ork,

fis

h, a

nd sh

ellfi

sh

expo

sed

to m

ercu

ry

com

poun

ds

Urin

e, b

lood

, hai

rFi

sh c

augh

t in

wat

ers

cont

amin

ated

with

m

ercu

ry c

ompo

unds

, an

imal

s fed

with

gra

ins

treat

ed w

ith fu

ngic

ides

co

ntai

ning

mer

cury

, in

gesti

on o

f mer

cury

, in

gesti

on o

f gra

ins

treat

ed w

ith m

ercu

ry o

r m

eat f

rom

ani

mal

s fed

w

ith th

ose

grai

ns


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Trio

rthoc

resy

l ph

osph

ate

poiso

ning

Trio

rthoc

resy

l ph

osph

ate

used

as

an

extra

ct o

r as

a su

bstit

ute

for

kitc

hen

oil

From

5 to

21

days

, av

erag

e 10

day

sG

astro

inte

stina

l sy

mpt

oms,

pain

s in

the

legs

, ver

y ac

cent

uate

d eq

uine

ga

it, li

mpn

ess o

f fee

t an

d w

rist

Cook

ing

oils,

ex

tract

s and

ot

her f

oods

tuffs

co

ntam

inat

ed

with

trio

rthoc

resy

l ph

osph

ate

Biop

sy o

f the

ga

stron

emiu

s m

uscl

e

Use

of t

he c

ompo

und

as a

n ex

tract

or a

s oil

for

cook

ing

or fo

r sal

ads

5. M

anife

stat

ion

of s

igns

and

sym

ptom

s of

gen

eral

ized

infe

ctio

n (fe

ver,

chill

s, d

isco

mfo

rt, p

ains

)

5.1

Incu

batio

n pe

riod

betw

een

12-7

2 ho

urs

Bact

eria

l age

nts

Infe

ctio

n ca

used

by

Vibr

io v

ulni

ficus

Vibr

io v

ulni

ficus

16 h

ours

Sept

icae

mia

, fev

er,

mal

aise

, pro

strat

ion,

ty

pica

l of c

ases

w

ith p

revi

ous l

iver

pr

oble

ms

Oys

ters

and

raw

cl

ams

Bloo

dPe

ople

with

live

r pr

oble

ms

Anth

rax

Baci

llus a

nthr

acis

From

3 to

5 d

ays

Gas

troen

terit

is,

vom

iting

, ha

emor

rhag

ic

depo

sitio

ns

Mea

t fro

m si

ck

anim

als

Stoo

l, vo

miti

ngCl

inic

al m

anife

statio

ns

afte

r con

sum

ptio

n of

m

eat f

rom

sick

ani

mal

s

Stre

ptoc

occu

s sui

s in

fect

ion

Stre

ptoc

occu

s sui

s3

hour

s to

14 d

ays

Hea

dach

e, fe

ver,

vom

iting

, men

ingi

tis,

sept

icae

mia

, en

doca

rditi

s, to

xic

shoc

k sy

ndro

me,

ar

thrit

is, a

cute

de

afne

ss

Infe

cted

pig

s or

cont

amin

ated

por

kCS

F or

blo

od

sam

ples

Dire

ct c

onta

ct w

ith

infe

cted

or c

onta

min

ated

m

ater

ials,

pro

cess

ing

or

cons

umin

g un

cook

ed

or p

artia

lly c

ooke

d po

rk

prod

ucts


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

5.2

Incu

batio

n pe

riod

long

er th

an 1

wee

k

Bact

eria

l age

nts

Bruc

ello

sisBr

ucel

la a

bortu

s, B.

m

elite

nsis,

and

B.

suis

in ti

ssue

s and

m

ilk o

f inf

ecte

d an

imal

s

From

7 to

21

days

Feve

r, ch

ills,

swea

ts,

wea

knes

s, m

alai

se,

head

ache

, mya

lgia

an

d ar

thra

lgia

, w

eigh

t los

s

Raw

milk

, goa

t ch

eese

mad

e w

ith

raw

milk

Bloo

dU

npas

teur

ized

milk

, liv

esto

ck in

fect

ed b

y br

ucel

losis

, con

tact

with

ab

orte

d m

ater

ials

Tube

rcul

osis

Myc

obac

teriu

m

bovis

4–12

wee

ksLu

ng le

sions

ba

sical

ly b

ut a

lso in

ki

dney

s, liv

er, s

plee

n an

d co

rresp

ondi

ng

node

s

Raw

milk

and

mea

tCu

lture

from

se

cret

ions

or

tissu

es

Cons

umpt

ion

of ra

w

milk

, con

sum

ptio

n of

ra

w in

fect

ed m

eat f

rom

do

mes

tic o

r wild

ani

mal

s

Liste

ria in

fect

ion

Liste

ria

mon

ocyt

ogen

es3

to 7

0 da

ys,

usua

lly 4

to 2

1 da

ys

Feve

r, he

adac

he,

naus

ea, v

omiti

ng,

abor

tion,

men

ingi

tis,

ence

phal

itis,

and

seps

is

Milk

, fre

sh c

hees

e,

proc

esse

d m

eats

Bloo

d, u

rine

Impr

oper

coo

king

, non

-pa

steur

izat

ion

of m

ilk,

prol

onge

d co

olin

g

Typh

oid

and

para

typh

oid

feve

rS.

ent

eric

a Se

roty

pe

typh

i fou

nd in

fa

eces

of i

nfec

ted

peop

le, o

ther

se

roty

pes (

as

para

typh

i A, c

hole

ra

suis)

for c

ases

of

para

typh

oid,

faec

es

of h

uman

s and

an

imal

s

From

7 to

28

days

, av

erag

e 14

day

sM

alai

se, h

eada

che,

fe

ver,

coug

h,

naus

ea, v

omiti

ng,

cons

tipat

ion,

ab

dom

inal

pai

ns,

chill

s, ro

se sp

ots,

bloo

dy st

ool

Shel

lfish

, foo

d co

ntam

inat

ed b

y ha

ndle

rs, ra

w m

ilk,

chee

se, w

ater

cres

s, w

ater

Stoo

l, re

ctal

sw

abs,

bloo

d in

ear

ly p

art o

f th

e ac

ute

phas

e,

urin

e in

the

acut

e ph

ase

Infe

cted

han

dler

s to

uchi

ng fo

od, p

oor

perso

nal h

ygie

ne,

impr

oper

coo

king

, in

adeq

uate

refri

gera

tion,

im

prop

er w

aste

wat

er

disp

osal

, acq

uisit

ion

of

food

from

con

tam

inat

ed

sour

ces,

harv

estin

g of

sh

ellfi

sh fr

om w

ater

s co

ntam

inat

ed w

ith

sew

age


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Vira

l age

nts

Hep

atiti

s AH

epat

itis A

viru

s fo

und

in th

e fa

eces

, ur

ine,

or b

lood

of

infe

cted

peo

ple

and

othe

r inf

ecte

d no

n-hu

man

prim

ates

From

10

to 5

0 da

ys, a

vera

ge 2

5 da

ys

Feve

r, m

alai

se,

lass

itude

, ano

rexi

a,

naus

ea, a

bdom

inal

pa

ins,

jaun

dice

Shel

lfish

, any

food

co

ntam

inat

ed w

ith

hepa

titis

viru

s, w

ater

Stoo

l, ur

ine,

bl

ood

Infe

cted

han

dler

s to

uchi

ng fo

od, p

oor

perso

nal h

ygie

ne,

impr

oper

coo

king

, ha

rves

ting

shel

lfish

from

w

ater

s con

tam

inat

ed

with

sew

age,

impr

oper

di

spos

al o

f was

tew

ater

Hep

atiti

s EH

epat

itis E

viru

sFr

om 1

5 to

65

days

usu

ally

35

to 4

0

Sim

ilar t

o ab

ove

(hig

h m

orta

lity

for

preg

nant

wom

en)

Shel

lfish

, any

food

co

ntam

inat

ed w

ith

hepa

titis

viru

s, w

ater

Stoo

l, ur

ine,

bl

ood

Infe

cted

han

dler

s to

uchi

ng fo

od, p

oor

perso

nal h

ygie

ne,

impr

oper

coo

king

, ha

rves

ting

shel

lfish

from

w

ater

s con

tam

inat

ed

with

sew

age,

impr

oper

di

spos

al o

f was

te w

ater

Para

sitic

age

nts

Angi

ostro

ngy-

liasis

(Eos

inop

hilic

m

enin

goen

ceph

aliti

s)

Angi

osgt

rong

ylus

cant

onen

sis (l

ung-

wor

m o

f rat

s) fo

und

in ro

dent

dro

ppin

gs

and

the

soil

From

14

to 1

6 da

ysG

astro

ente

ritis,

he

adac

he, s

tiffn

ess

of th

e ne

ck a

nd

back

, low

-gra

de

feve

r

Crab

s, pr

awns

, slu

gs, s

hrim

p, ra

w

snai

ls

Bloo

dIm

prop

er c

ooki

ng

Toxo

plas

mos

isTo

xopl

asm

a go

ndii

foun

d in

tiss

ues a

nd

mea

t of i

nfec

ted

anim

als

From

10

to 1

3 da

ysFe

ver,

head

ache

, m

yalg

ia, c

utan

eous

ra

sh

Raw

or

unde

rcoo

ked

mea

tLy

mph

nod

es (f

or

biop

sy),

bloo

dIm

prop

er c

ooki

ng o

f m

utto

n, p

ork,

bee

f or

veal


Dise

ase

Etio

logi

c ag

ent o

r ca

use

Incu

batio

n pe

riod

(late

ncy)

Sign

s an

d sy

mpt

oms

Food

impl

icat

ed

Spec

imen

s to

be

obt

aine

dCo

ntrib

utin

g fa

ctor

s

Tric

hino

sisTr

ichi

nella

sp

iralis

foun

d in

po

rk a

nd b

ear m

eat

From

4 to

28

days

, av

erag

e 9

days

Gas

troen

terit

is, fe

ver,

oede

ma

arou

nd th

e ey

es, m

yalg

ia, c

hills

, pr

ostra

tion,

diff

icul

ty

brea

thin

g

Pork

, bea

r, w

alru

sM

uscl

e tis

sue

(for

biop

sy)

Inge

stion

of

unde

rcoo

ked

pork

or

bear

mea

t, im

prop

er

cook

ing

or te

mpe

ratu

res,

feed

ing

pigs

with

ga

rbag

e th

at h

as n

ot

been

coo

ked

or p

rope

rly

treat

ed w

ith h

eat

6. A

llerg

ic s

ympt

oms

and

sign

s (fl

ushi

ng a

nd it

chin

g of

the

face

)

Incu

batio

n pe

riod

less

than

1 h

our

Bact

eria

l age

nts (

and

anim

als)

Scom

broi

d po

isoni

ng

(Hist

amin

e Po

isoni

ng)

Hist

amin

e-lik

e su

bsta

nces

pr

oduc

ed

by P

rote

us sp

p.

or o

ther

hist

idin

e ba

cter

ia fo

und

in

the

flesh

of f

ish

From

a fe

w

min

utes

to 1

hou

rH

eada

che,

diz

zine

ss,

naus

ea, v

omiti

ng,

pepp

ery

taste

, bu

rnin

g in

the

thro

at, f

acia

l sw

ellin

g an

d flu

shin

g, c

olic

, itc

hing

Tuna

fish

, blu

e m

acke

rel,

Paci

fic

dolp

hin,

che

ese

Vom

itIn

adeq

uate

refri

gera

tion

of sc

ombr

oid

fish,

im

prop

er c

urin

g of

ch

eese

Chem

ical

age

nts

Mon

osod

ium

glu

tam

ate

poiso

ning

Exce

ssiv

e qu

antit

y of

mon

osod

ium

gl

utam

ate

From

a fe

w

min

utes

to 1

hou

rBu

rnin

g se

nsat

ion

in

the

back

of t

he n

eck,

fo

rear

ms a

nd c

hest;

tig

htne

ss, t

ingl

ing,

fa

cial

flus

hing

, di

zzin

ess,

head

ache

, na

usea

Food

seas

oned

w

ith m

onos

odiu

m

glut

amat

e

U

se o

f exc

essiv

e qu

antit

ies o

f m

onos

odiu

m g

luta

mat

e to

enh

ance

flav

our.

Onl

y so

me

indi

vidu

als a

re

sens

itive

to th

e M

SG

Nic

otin

ic a

cid

poiso

ning

(nia

cin)

Sodi

um n

icot

inat

e us

ed a

s col

our

pres

erva

tive

From

a fe

w

min

utes

to a

n ho

urRe

dden

ing,

hot

fla

shes

, itc

hing

, ab

dom

inal

pai

ns,

swel

ling

of th

e fa

ce

and

knee

s

Mea

t or o

ther

food

to

whi

ch so

dium

ni

cotin

ate

has b

een

adde

d

U

se o

f sod

ium

nic

otin

ate

to p

rese

rve

colo

ur


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,


(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.


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

– 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.


(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.


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.


Annex 3: Categorization of subgroups under WHO regionsSubregion 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; Cote 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.


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.

World Health House

Indraprastha Estate,

Mahatma Gandhi Marg,

New Delhi-110002, India

www.searo.who.int

in the South-East Asia Region

foodborne diseasesBurden of

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.

9 789290 225034

ISBN 978-92-9022-503-4

burden of foodborne diseases - who

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