Burden of foodborne diseases: think global, act local
Sara M Pires
1,14, Binyam N Desta
2, Lapo Mughini-Gras
3,4, Blandina T Mmbaga
5,6, Olanrewaju E Fayemi
7, Elsa M Salvador
8, Tesfaye
Gobena
9, Shannon E Majowicz
2, Tine Hald
1, Peter S Hoejskov
10, Yuki Minato
11and
Brecht Devleesschauwer
12,13Nationalburdenoffoodbornedisease(FBD)studiesareessential toestablishfoodsafetyasapublichealthpriority,rankdiseases, andinforminterventions.Inrecentyears,variouscountrieshave takenstepstoimplementthem.Despiteprogress,thecurrent burdenofdisease landscaperemainsscattered, and researchers struggletotranslatefindingstoinputforpolicy.Wedescribethe currentknowledgebaseonburdenofFBDs,highlightexamples ofwell-establishedstudies,andhowresultshavebeenusedfor decision-making.Wediscusschallengesinestimatingburdenof FBDinlow-resourcesettings,andtheexperienceand opportunitiesderivingfromalarge-scaleresearchprojectin thesesettings.Lastly,wehighlighttheroleofinternational organizationsandinitiativesinsupportingcountriestodevelop capacityandconductstudies.
Addresses
1NationalFoodInstitute,TechnicalUniversityofDenmark,Lyngby, Denmark
2SchoolofPublicHealthandHealthSystems,UniversityofWaterloo, Waterloo,Canada
3NationalInstituteforPublicHealthandtheEnvironment,Bilthoven,The Netherlands
4UtrechtUniversity,InstituteforRiskAssessmentSciences,Utrecht, TheNetherlands
5KilimanjaroClinicalResearchInstitute-KilimanjaroChristianMedical Centre,Moshi,Tanzania
6KilimanjaroChristianMedicalUniversityCollege,Moshi,Tanzania
7DepartmentofBiologicalSciences,MountainTopUniversity,Ibafo, OgunState,Nigeria
8DepartmentofBiologicalSciences,FacultyofSciences,Eduardo MondlaneUniversity,Maputo,Mozambique
9CollegeofHealthandMedicalScience,HaramayaUniversity,Ethiopia
10WorldHealthOrganization,Copenhagen,Denmark
11WorldHealthOrganization,Geneva,Switzerland
12DepartmentofEpidemiologyandPublicHealth,Sciensano,Brussels, Belgium
13DepartmentofVeterinaryPublicHealthandFoodSafety,Ghent University,Merelbeke,Belgium
Correspondingauthor:Pires,SaraM(smpi@food.dtu.dk)
14www.food.dtu.dk.
CurrentOpinioninFoodScience2021,38:152–159
ThisreviewcomesfromathemedissueonFoodmicrobiology EditedbyAndersondeSouzaSant’Ana
https://doi.org/10.1016/j.cofs.2021.01.006
2214-7993/ã2021TheAuthor(s).PublishedbyElsevierLtd.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.
org/licenses/by/4.0/).
Introduction
Foodbornediseases(FBD)stillcauseasubstantialpublic health,economic and social burden worldwide. Recog- nizingtheneedtomeasuretheburdenanddistributionof FBD and encourage evidence-informed policies, in 2015 the World Health Organization (WHO) reported thefirstestimatesofglobalandregionaldiseaseburden due to 31 foodborne hazards [1]. Results showed that, eachyear,1 outof10peoplegetillfromfoodcontami- nated with microbial or chemical agents, resulting in 600 million illnesses, 420000 deaths and the loss of 33millionhealthyyearsoflifeglobally[2].Whilethese estimateswerecrucialtoraiseawareness,theywerethe product of an enormous research initiative that faced substantial data gaps. Importantly, they did not offer theprecisionneededtoidentifyprioritiesatthenational level,andwerenot alwaysableto makeuse of alldata resourcesavailable.Precisenationaldiseaseburdenesti- mates are essential to identify the most important dis- eases and hazards in a country, as well as the foods contributingthemosttothesediseasesandtheinterven- tionsneeded toeffectivelypreventthem.
In recent years, various countries have recognized the needforstudiesofthenationalburdenofFBDs,andhave takenstepstoimplementthem.Despiteprogress,these representmostlyhighincomecountriesinafewregions of the world; pre-COVID, many other countries still lacked political commitment, technical and financial resources, and data to estimate the burden of FBDs, andweanticipate thesebarrierswillincrease as aresult of the pandemic. Furthermore, the current burden of disease landscape remains scattered, and researchers struggle to translate their findings to useable input for decisionmakers.
PromotingnationalburdenofFBDstudiesnowrelieson acombination of factors. First, theutility of burden of disease estimates for risk ranking, priority setting and efficientallocationofresourcesforfoodsafetyneedstobe communicatedto theappropriate targetaudiences,par- ticularly policy makers. Second, there is a need for harmonizingmethodologies,sharingdataanddatacollec- tionapproaches,andbuildingtechnicalcapacityincoun- triesandglobally;theseareimportantforcomparison of
estimatesacross diseases,countries andregions, andfor facilitating the study implementation process. Third, effortstoleverageonnoveltechnologiesandpossibilities for decreasingthecostsandfacilitatingwidespreaddata collection for burden of disease studies, particularly in low-income and middle-income countries (LMIC), should be made to ensure that all regionsof the world can have increasingly complete and robust burden of FBD estimates.
Theaimofthispaperistocontributetothisprocess.We describethecurrentknowledgebaseonburdenofFBDs, andhighlightexamplesofwell-establishednationalstud- ies,aswellastheutilityoftheirresultsforpolicymaking andestablishingpublichealthpriorities.Next,wediscuss themainchallengestoestimatingburdenofFBDinlow- resource settings,and theexperienceand opportunities deriving from a large-scale research project in these settings. Lastly, we highlight the role of international organizations,particularlytheWHO,insupportingcoun- tries todevelopcapacityandconductcountry-levelbur- den of disease studies. The contents described were compiledinthecontextofaworkshopheldattheWorld PublicHealthConference,October 2020[3].
Currentlandscape ofnationalburden of foodborne disease studies
The conceptof burdenof diseasewasdeveloped inthe 1990sbytheHarvardSchoolofPublicHealth,theWorld BankandtheWHOtodescribedeathandlossofhealth duetodiseases,injuriesandriskfactorsforallregionsof theworld[4].Whileburdenofdiseasecanbeexpressed using various indicators, such as incidence, mortality, societal costs and summary measures of population health,thisstudyintroducedanew metric,theDisabil- ity-Adjusted Life Year (DALY), which combines infor- mation on morbidity and mortalitycaused by diseases.
The DALY is now the mostwidely usedpublic health metricforburdenofdiseasestudies,andthekeymeasure in theGlobalBurdenof Disease(GBD)studies[5].
Thefirstestimatesoftheburdenoffoodbornediseasesin DALYs were published in 2000, measuring the health burdenofasinglefoodbornepathogenintheNetherlands [6].OtherstudiesfollowedinEuropeandbeyond,using the DALY metric to measure the burden of country- specificsinglepathogensorafewoffoodbornepathogens [7–14]. In 2015, the WHO produced the first global DALY estimatesoftheburdenofFBD[1].Afewother countries haveestablished burdenof FBD studiesafter that,publishingeitherroutineestimatesorad-hocreports orarticleswithestimatesforspecificpathogensandyears.
Theselargelyfocusonmicrobiologicalagentsandinclude mostly high-incomecountries, such as the Netherlands [15,16],Japan[17],Denmark[18,19],Belgium[20],and the United States of America [21]. Initiatives in low- income countries have taken the first steps to address
knowledge gaps. As examples, [22] estimated of the incidenceofillnessofFBDsfromsyndromicsurveillance data in Rwanda, and the Caribbean Burden of Illness Study estimated the prevalenceand incidence of acute gastroenteritisandspecific foodbornepathogensinnine countries[23].Thesearefirststepstonationalburdenof disease studies. Evidence on the burden of individual foodborne chemicals in some countries has also been published[24–26].Again, thesestudieswereconducted inhigh-incomecountries,wheredataaremoreabundant, butthediseaseburdenmaybelowerwhencomparedto LMIC.
EvenifavailableevidenceillustratesthatLMICsbeara higherburdenthanhigh-incomecountries,theemphasis isonthedatagaps.Forexample,theWHO’ssub-regional DALYestimatesforLMICsmajorlyreliedonimputation, where dataavailable fromsome countries wereusedto predictdatamissing fromothers,as datawerescarcein these countries [1,27,28–31]. Given the target of the WHO’sglobalDALYestimatesandlearninglessonsfrom thefewnationwidestudies,estimationoftheburdenof nation-based foodborne diseases would be suitable for informing interventionsandpolicy.
WHO-FERG’scountrystudiesefforts
The Foodborne Disease Burden Epidemiology Refer- enceGroup(FERG)wasestablishedbyWHOin2007to estimatetheglobalandregionalburdenofFBDs(across thesixWHOregions)[32].OtheraimsofFERGwereto strengthenthecapacityofcountriestoassesstheirburden ofFBD,andtoincreasethenumberofcountriesthathave undertakensuchastudy.ActivitiesofFERGtopromote national studies involved capacity-building and promo- tion of the use of information on burden of disease in settingevidence-informedpolicies.TheFERGCountry Studies Task Force(CSTF) developed a suiteof tools and resources to support national studies. Pilot studies wereconductedinAlbania,Japan,ThailandandUganda [31]andprovidedimportantpracticallessons.Inparticu- lar, data gaps impeded DALY calculations in several occasions. These gaps included information needed to assigntheetiologyforsyndromes,suchasacutegastroin- testinal disease, and data on the incidence of diseases causedbysomehazards.
The pilotstudiesalso highlightedtheneed for engage- mentofstakeholdersthatcanprovideaccesstonational data, includingpublicandprivatedatasources. Insome countries, privatehospitalsprovide asignificantpropor- tion of health care, and may not adhere to the same reportingrequirementsaspublichospitals.Engagement withprivatehospitalsandotherfacilitiesmayneedtobe specificallyaddressedtoprovideacompletepictureofthe incidence of FBDs.Data onfoodbornehazards maybe gatheredfromprimaryproducersand thefood industry, but economic implications, particularly for trade, may
constituteabarrierforsharingsuchdata,whichtherefore requirescareful handling.
TheCSTFconcludedthattheuseoffindingsfromnational burden of FBD studies is facilitatedwhenstakeholders witharoleandinterestinfoodsafety,suchasgovernmental institutions, academia, anddecision-makers (Ministry of Health,MinistryofAgriculture,MinistryofEnvironment, food safety authorities, public health agencies)— work closelywiththestudyteamfromtheearlieststages.They canbeinvolvedinearlyandcontinuouseffortstoincorpo- rateknowledgetranslationandriskcommunicationtothe relevantaudiences. Adetaileddescriptionof allcountry studiesandsupportmaterialsdevelopedbytheCSTFhas beenpublished[31].
Filling-in datagaps toestimate burdenof foodborne diseaseswhere dataare scarce LMICs,inparticularfromAfrica,bearthehighestburden ofFBDs [2,27].IntheAfricanregion wheretheFBD burdenisthehighest,the31foodbornehazardsincluded intheWHOestimatesoftheglobalburdenofFBDhave beenestimated tocause1200–1300 DALYsper100000 inhabitantsin2010,comparedto35–711inotherregions.
Nearly 70% of the burden is due to diarrheal disease agents, particularlyto non-typhoidalSalmonella(includ- ing invasive salmonellosis), and Enteropathogenic and Enterotoxigenic Escherichiacoli.Other importantagents includedVibriocholeraeand Taeniasolium [1].However, because research and disease surveillance data from Africa arelimited, theseestimatesare subjecttouncer- tainty.ThemainchallengetoestimatingburdenofFBD inAfrica islackof data,particularlyontheincidenceof FBDs in the population. This limited availability is caused by various factors, such as the lack of capacity to generate, compileand analysedata, limited political commitmenttostrengthensurveillancesystems,limited understandingofthebenefitsofburdenofdiseasestudies andafocusonselectednotifiableprioritydiseases.
To address this, a multi-country project launched in 2019in Ethiopia,Mozambique,Nigeria, and Tanzania, aimsto estimate theburdenof, andstrengthen surveil- lance systems for, FBDs in Africa [33]. The team is conductingapopulation-basedsurvey (toestimate inci- denceofdiarrheainthecommunity),asystematicliter- aturereview(toestimateproportionsofdiarrhealdisease caused by different agents), and an active review of availableFBDreports(to estimatetheextentof under- reportinginexistingsurveillance).Together,thesefind- ingswillprovidemoreaccurateestimatesoftheburdenof FBDsinAfricancontexts.Thetoolsandlessonsfromthis large-scaleprojectcanbeextrapolatedtoothercountries andregionswheretheburdenishigh,butdataarescarce.
Thedatacollectiontoolsbeingdevelopedwillbeavail- able to be adapted for other settings. Other highlights include applying leadership roles, delegation of duties
and project tasks, setting milestones, regular meetings, andrisk-mitigation plans. Because of theirlocal knowl- edgeonFBDsandofthefunctioningofinstitutions,the leading role of experts in this project helps to reduce hurdles.The projecthasalso adaptedexisting datacol- lection tools such as questionnaires and survey study design for use across the diverseAfrican study popula- tions. It is engaging stakeholders, including policy- makers, who will use its research outputs,by involving thematallstagesoftheproject.Thisintegratedknowl- edgetranslationapproachistranslatabletoothersettings.
Usingnovelmethodologiestosupportburden ofdisease estimates
An apparent challenge to estimating burden of FBDs, particularly in LMICs, where laboratory capacity and surveillancesystemsare limited, isobtainingvalid esti- matesofetiologyproportionsofcases.Acommonlyused methodissystematicreviewof studiesreportingpatho- genisolationindiarrheacases[34–36].However,studies oftendifferindesign,population,timeframe,andpatho- gens included, hampering extrapolation to the target population.
The above-mentioned project is exploring a novel approachfor estimatingdiarrhea etiologyproportions in urbanandruralpopulationsinthefourAfricancountries [37].It analyses sewage samplesusing short-read next- generationsequencing(NGS)todetermineabundanceof genes that canbe mapped to specific bacterial genera, providinganestimateoftherelativeabundanceofpatho- gens in each sample. By combining results with the diarrhealincidence estimated in parallel,pathogen-spe- cific incidence will be estimated and compared with incidenceestimatesfromthetraditionalapproach.
The application of NGS to human sewage has great potential for surveillance of FBDs, particularly in resource-poorsettingswherelaboratorycapacityforbac- terialisolation is limited. First, NGS is a‘one method takesall’ approach,as it isbased ondetectionof RNA/
DNA,alanguagecommonacrosspathogens.Second,itis culture-independent,allowingforreal-timedatagenera- tionand standardized sharing. Finally,few samples are neededtosurveylargepopulationsforseveralpathogens at the same time. Thus, surveillance based on NGS appliedto sewagemayprovetobean indirectmeasure ofincidence.Althoughitwillnotprovideanestimatefor thetrueincidenceinthepopulation,itwillincreaseour understandingoftheburdenand,assuch,beaproxyand novelwayofrankingdiseases.However,thesustainabil- ityof theapplication of NGS in resource-poor settings remainsanissue andwillrequiredirectingresourcesfor buildingcapacity.
From sciencetopolicy: the experienceof well-established burdenoffoodbornedisease studies
EstimatesoftheburdenofFBDsareusefultoprioritize food safety policy and allocate resources to where food safety risks arehighest. Theexperiences ofestablished studiesandoftheirmechanismsoftranslationofevidence intopolicycanprovideguidanceandsuggestprocessesfor other national studies. Here we focus ontwo countries that havebeen at theforefrontof burdenof FBD esti- mation:theNetherlandsandDenmark.
TheNetherlands
BurdenofFBDestimateshavebeenpublishedeveryyear in theNetherlandssince2008[14,38].The DutchMin- istryofHealthmandatestheDutchNationalInstitutefor PublicHealthand theEnvironment(RIVM)to provide annualupdatesofthenumberofillnesses,diseaseburden and cost-of-illness caused by an agreed-upon panel of 14 enteric pathogens mainly transmitted by food. The disease burden is expressed in DALYs. The cost-of- illness related to these pathogens isestimated in euros (s), and includes healthcare costs, the costs for the patient, family and caregivers (e.g. travel and external care expenses), and costs in other sectors, for example productivitylosses[14,39].Demographicdata,aswellas dataonmortality,livebirthsandstillbirths,areobtained from the Dutch Central Bureauof Statistics. The inci- denceofinfectionsbypathogenisobtainedfromvarious surveillancesystems.Forinstance,dataonpathogenslike Listeria monocytogenes, Shiga-toxin producing E. coli (STEC)O157andhepatitisAvirus,whicharenotifiable, are obtained from case notifications and the laboratory surveillance system, which has national coverage. For pathogens thatare not (mandatorily)notifiable, suchas Campylobacter,Salmonella,Cryptosporidium,norovirusand rotavirus, data are obtained from case notifications or laboratory surveillance based on networks of sentinel diagnosticlaboratories.The collecteddataarecorrected forgeographicalcoverageofthesurveillancesystemand for under reporting, to obtain an estimate of the inci- dence. Moreover, using different approaches to source attribution,theestimatedDALYsandcostestimatesare attributedtofivemajortransmissionpathways(i.e.food, environment,directanimalcontact,human-humantrans- mission,travel)and11foodgroupswithinthefoodborne pathway.TheRIVMhasregularlypublishedtheburden and cost estimates on its website and in reports, for example [39].
The most recent estimates, for 2019, show that the 14 pathogens are cumulatively responsible for about 11000DALYsands423million[40].Theshareappor- tioned to foodborne transmission is estimated at 4200 DALYsand s174 million.The largestfoodborne burden atpopulationlevelwascausedbyCampylobacter, followedbyToxoplasmagondiiandnorovirus.Regarding
otherfoodbornebacteria,Salmonellarankedsecondafter Campylobacter spp. Perinatal listeriosis and congenital toxoplasmosis were the diseases with the highest indi- vidual burden. The pathogenscausing the largestcosts were norovirus, rotavirus, Staphylococcus aureus, and Campylobacter. However, the average cost per case was largest for perinatallisteriosis (s 291000/case).Health- care costs accounted for 21% of the total costs for the 14 pathogens, patient and family costs for 2%, and the costsinothersectorsaccountedfor77%.About41%ofthe foodborne burden was associated with meat, that is, poultry, pork, beef and lamb, which caused 33% of all food-related fatal cases, indicating that the pathogens associatedwith thesefoodsare responsibleforthemost severeinfections.
Year after year, these national estimateshave provided vitalinsightsforpolicy-makingastoguidestrategies,such asestablishingprocesshygienecriterionforCampylobacter onbroilermeat[41].Yet,theyplayanevenmorevitalrole in resource allocation, suchas fundingfor research and other activities onspecific pathogensor conditions that appear to have a higher burden. Burden and cost esti- mates alsoenablepolicy-makersand thescientificcom- munitytomonitortrendsandgeneratescientifichypoth- eses. For instance, although the disease burden for Campylobacter had continually decreased since 2010, it slightlyincreasedin2018and2019,suggestingabegin- ning of a reversal of the trend. This calls for more research, such as studiesfocusing onhygiene measures at primary production, performanceof surveillanceand diagnostics, risk factor analyses, as well as genomics of circulatingstrains,to understandtheunderlyingcauses.
Denmark
ThefirstDanishburdenofFBDstudywaspublishedin 2014,and hasbeen growingwith new hazardsand data beingadded atdifferentpoints in time [18,42,43].The study currently includes microbiological and chemical hazards commonlypresent infoods.
Themostrecentestimatesformicrobiologicalagentsare from 2017 and cover seven pathogens that are mostly transmitted through foods: Campylobacter, Salmonella, STEC, norovirus,Yersinia enterocolitica,L.monocytogenes, andToxoplasmagondii.
In 2017, Campylobacter caused the highest burden of disease, more than threefold higher than the second highestrankedpathogen,Salmonella.ListeriaandYersinia followedintheranking.Theburdenofcongenitaltoxo- plasmosis was lower than most ofthe investigated dis- eases but was borne by a low number of cases in the population.
Therankingoffoodbornepathogensvariedsubstantially whenbasedonreportedcases,estimatedincidence,and
burden of disease estimates. The total estimated inci- dence was highest for norovirus, but this agent ranked sixthwhen focusing on foodborne burdenmeasured in DALYs. These differencesillustrate the importance of estimating burden of disease in DALYs, particularly whenthepurposeistocompareacrossdiseaseswithvery diverseseverityand duration.
Mostofthefoodbornepathogenscanalsobetransmitted throughnon-foodborneroutes,andthestudypartitionsto overallburden of diseaseto foods,and,forsomepatho- gens,linkswithsourceattributionestimatesfor specific foods. For attribution to main transmission routes, the burdenestimateswerelinkedwiththesourceattribution proportions estimatedfor the Europeansub-region that includesDenmarkbytheFERG’sexpertelicitation[44].
Campylobacter still led the ranking when excluding DALYsattributabletonon-foodborneroutesofexposure, buttherankingofsomeoftheotherpathogens(particu- larlynorovirus)changed.
Whiletheseestimateswerenotinitiallyrequestedbythe Danish Veterinary and Food Administration (DVFA), theyarenowusedtoidentifyprioritiesandtodetermine efforts for further surveillance and interventions, to informallocationofresourcesforresearch,ortopromote discussionsofthepublichealthrelevanceofpathogensin thecountry.For example,theDVFA formedpathogen- specific interest groups that gather experts from public health,foodandanimalsurveillancetodiscusspriorities and define needs to inform policy. Among these, the Campylobacter Interest Group, formed in 2017, meets approximately four times a year to discuss how stake- holderscanmakethebestuseofthedatageneratedand theknowledgegainedfromresearchandsurveillancedata for a better monitoring of Campylobacter in food and humans.Theinterestgroupalsocontributesinformation on research, including routes of infection, infection dynamics,andgeneticmethodsto distinguishcampylo- bacterfromdifferentsources. TheDVFAhasalsoiniti- atedseveralactivitiesintheparasiticarea,includingarisk profileoffoodborneparasitesinDenmark,and commu- nicationofinformationto theconsumer.
Capacitybuildingand support from international organizations
Inlinewith globalandregionalstrategiesand basedon country-support plans and biennialcollaboration agree- mentswithMemberStates,WHO,incollaborationwith itspartners andcollaboratingcentres,providestechnical assistancetocountriestostrengthennationalfoodsafety systems. Thisincludes technical assistance to generate, collectandanalysefoodsafetyevidence,includinginfor- mation about the burden of FBDs. For instance, in Vietnam, identification of priority pathogens for FBDs informedtheexpansionoftheemergingdiseasesurveil- lancesystem andstrengtheningIHR corecapacitiesfor
surveillanceinthecountry,andinAlbania,apilotstudy onthenationalburdenofFBDsprovidedimportantinput to the process of reorganizing and strengthening the nationalfood safetysystem[45,46].
WHOhasacriticalroleinprovidingevidenceforactionto improve food safety and to support member states to effectivelycollect,analyse,reportandusedataonFBDs [47].TheWHOestimatesoftheglobalburdenofFBDs werethefirsteverattempttodescribethemagnitude of suchTomonitortrendsintheglobalburdenofFBDsand provideanupdatedbasis forfoodsafetypolicydevelop- ment, WHO has started the process of updating the 2010estimates.Thisincludesareviewofthemethodology andepidemiologicaldata,identificationoftechnicalgaps andprioritiesforresearch,andestablishmentoftaskforces and othermeans through whichscientific and technical mattersrelatedtotheburdenofFBDscanbeaddressed.
WHOisalsoacceleratingitseffortsandsupporttomem- berstatestoestimatethenationalburdenofFBDs.This isdonethroughtechnicalassistanceanddevelopmentof guidancetoassesstheburdenofFBDscausedbymicro- biologicalagentsatnationallevel.Theguidanceincludes acompletepictureoftherequirements,enablingfactors, challengesand opportunities to estimate theburden of FBDs,andofthestepsfor derivingtheestimates.
WHOpromotestheuseofharmonizedmethodologiesfor estimatingfoodbornediseaseburdenacrosscountries.A harmonizedapproachprovidesan opportunityforcoun- tries to compare their disease burden with the one of other countries and is essential for experiences to be sharedandfood safetypolicyto beimproved.
InadditiontotheWHO,otherinternationalorganizations are playing a pivotal role in quantifying national and global (foodborne) disease burden. Most notably, the Institutefor Health Metrics and Evaluation (IHME) is responsible for the GBD study, currently generating estimatesfor369diseasesandinjuriesand87riskfactors in204countriesandterritories[48].Whilefoodsafetyis notincluded as a separate entity, theGBD study does cover several individual FBDs. In collaboration with IHME,theGlobalBurdenofAnimalDiseases(GBADs) programme, which is being developed by a group of internationalcollaboratorsledbytheUniversityofLiver- pool, United Kingdom, has recently been established.
The programme aims to strengthen and complete the GBDestimatesofFBDburdenandtoleveragetheseto evaluate food safety [49].These initiatives will further promotetheinclusionoffoodsafetyontheglobalhealth agenda.
Stepsforward
ThegroundforpromotingnationalburdenofFBDsstudies isbeingpaved.Totaketheawarenessoftheusefulnessof
burdenofdiseasestudiestoguidefoodsafetyinterventions inthedirectionofactualimplementationofstudies,inter- national organizations,localauthoritiesandthescientific communitywillhavespecificandmultipleroles.
Burden of foodbornediseasestudiesmakethebasisfor informedriskmanagementdecisions.Thisisakeyprior- ityoftheforthcomingGlobalFoodSafetyStrategydevel- oped by WHO. The strategy will serve as a strategic frameworktoguideactionofgovernmentstostrengthen- ing nationalfood safetycontrolsystems. The upcoming WHOguidancetoestimateburdenofFBDin countries and planned activities for capacity building will play a crucial part in encouraging countries to develop and launch their national studies. While these will needto beaccompaniedbyresourcestoimplementandrunthe project, they may motivate institutions and/or research groups to start with small-scale projects that have the potentialto beextendedovertime.
Along with thesupportfrominternationalorganizations (suchas WHO),networksofexpertswith experiencein burden of disease studies are of value for technical support,knowledgesharingandharmonizationof meth- ods. One of these is the European Burden of Disease Network(COSTActionCA18218,www.burden-eu.net), whichisalreadycontributingwithinitsEuropeanmem- bers and associated partners from other regions. The sustainability and expansion of this and similar efforts can bean important contributionfor an increase in the numberof nationalburdenofFBD studies.
Furthermore,thedevelopmentanddisseminationofnew approaches and data collection tools, particularly for LMIC, willbevaluable toovercomeone ofthebiggest challengesfacedsofar—thedatascarcityfacedinmany countriesglobally.Innovativetoolshavethepotentialof being of faster, wider and cheaper application, thus reducingthe disparityof dataavailabilitybetween high incomecountriesandLMIC.
Burden of diseasecanbe expressedusing various indi- cators, such as incidence, mortality, societal costs and summary measures of populationhealth. The DALY is recognizedastheultimatesummarymeasureforquanti- fyingthepopulationhealthimpactoffoodbornediseases.
WhileestimatingDALYsisanaspirationalgoal,anystep towards it isvaluable. Estimates of incidenceand mor- tality canalso be usedto rank and compare the public healthimpactofFBDsandshouldbeencouragedtotake as afirststepinburdenof diseasestudies.
Declaration ofinterests
Theauthorsdeclarethattheyhavenoknowncompeting financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
Theauthorswouldliketoacknowledgethenetworkingsupportfrom COSTActionCA18218(EuropeanBurdenofDiseaseNetwork,www.
burden-eu.net),supportedbyCOST(EuropeanCooperationinScienceand Technology,www.cost.eu).
SMP,SM,BD,BTM,OEF,EMS,TGandTHarepartoftheprojectteam forFOCAL(FoodborneDiseaseEpidemiology,SurveillanceandControlin AfricanLMIC).FOCALisamulti-partner,multi-studyprojectco-funded bytheBillandMelindaGatesFoundationandtheForeign,Commonwealth
&DevelopmentOffice(FCDO)oftheUnitedKingdomGovernment [GrantAgreementInvestmentIDOPP1195617].
Partofthismanuscriptwascompiledundertheworkshop‘Burdenof FoodborneDiseaseStudies:MethodsandRelevanceofNationalStudies’, hostedbythe16thWorldCongressonPublicHealth(12–16thOctober 2020),wcph2020.com.
References and recommendedreading
Papersofparticularinterest,publishedwithintheperiodofreview, havebeenhighlightedas:
ofspecialinterest
1. WHO:WHOEstimatesoftheGlobalBurdenofFoodborne Diseases.WHO;2015.
2.
HavelaarAH,KirkMD,TorgersonPR,GibbHJ,HaldT,LakeRJ, PraetN,BellingerDC,deSilvaNR,GargouriNetal.:WorldHealth Organizationglobalestimatesandregionalcomparisonsof theburdenoffoodbornediseasein2010.PLoSMed2015,12:1- 23
TheWHOpublishedthefirsteverestimatesoftheGlobalandRegional BurdenofFoodborneDiseases.Thestudywascrucialtoraiseawareness forthepublichealthimpactoffoodbornediseases,andtopointtofood safetyprioritiesindifferentregionsglobally.
3. PiresSM,Mughini-GrasL,DestaBN,MajowiczS,HaldT, HoejskovPS,DevleesschauwerB:Burdenoffoodborne disease:methodsandrelevanceofnationalstudies.EurJ PublicHealth2020,30.
4. MurrayCJL:Quantifyingtheburdenofdisease:thetechnical basisfordisability-adjustedlifeyears.BullWorldHealthOrgan 1994,72:429-445.
5.
MathersCD:Historyofglobalburdenofdiseaseassessmentat theWorldHealthOrganization.ArchPublicHealth2020,78:77 Theauthorgivesanhistoricalperspectiveoftheglobalburdenofdisease study,anddiscussesthestrengthsoftheburdenofdiseaseapproachto informpublichealthpolicyatnationalandgloballevels.
6. HavelaarAH,deWitMA,vanKoningsveldR,vanKempenE:
HealthburdenintheNetherlandsduetoinfectionwith thermophilicCampylobacterspp.EpidemiolInfect2000, 125:505-522.
7. HavelaaraH,VanDuynhovenYT,NautaMJ,BouwknegtM, HeuvelinkAE,DeWitGA,NieuwenhuizenMG,vandeKarNC:
DiseaseburdenintheNetherlandsduetoinfectionswith Shigatoxin-producingEscherichiacoliO157.EpidemiolInfect 2004,132:467-484.
8. LakeRJ,CresseyPJ,CampbellDM,OakleyE:Riskrankingfor foodbornemicrobialhazardsinNewZealand:burdenof diseaseestimates.RiskAnal2010,30:743-752.
9. BatzMB,HoffmannSA,MorrisJG:RankingtheRisks:The 10Pathogen-FoodCombinationswiththeGreatestBurdenon PublicHealth.EmergingPathogensInstituteatUniversityof Florida;2011.
10. GkogkaE,ReijM,HavelaarA,ZwieteringM,GorrisL:Risk-based estimateofeffectoffoodbornediseasesonpublichealth, Greece.EmergInfectDis2011,17.
11. ReijMW,JongenburgerI,GkogkaE,GorrisLGM,ZwieteringMH:
PerspectiveontherisktoinfantsintheNetherlands associatedwithCronobacterspp.occurringinpowdered infantformula.IntJFoodMicrobiol2009,136:232-237.
12. VerhoefL,KoopmansM,VanPeltW,DuizerE,HaagsmaJ, WerberD,VanAstenL,HavelaarA:Theestimateddisease burdenofnorovirusintheNetherlands.EpidemiolInfect2013, 141:496-506.
13. vanLierEA,HavelaarAH,NandaA:Theburdenofinfectious diseasesinEurope:apilotstudy.Eurosurveillance2007,12:3-4.
14. HavelaarAH,HaagsmaJA,MangenMJJ,KemmerenJM, VerhoefLPB,VijgenSMC,WilsonM,FriesemaIHM,KortbeekLM, vanDuynhovenYTHPetal.:Diseaseburdenoffoodborne pathogensintheNetherlands,2009.IntJFoodMicrobiol2012, 156:231-238.
15. VanLierA,McDonaldSA,BouwknegtM,VanDerSandeM, BijkerkP,VanBenthemB,Hahne´ S,VanDerHoekW,VanPeltW, HeijneJetal.:Diseaseburdenof32infectiousdiseasesinthe Netherlands,2007-2011.PLoSOne2016,11:2007-2011.
16. HavelaarA,HaagsmaJ,MangenM,KemmerenJ,VerhoefL, VijgenS,WilsonM,FriesemaI,KortbeekL,vanDuynhovenYetal.:
DiseaseburdenoffoodbornepathogensintheNetherlands, 2009.IntJFoodMicrobiolElsevier2012,156:231-238
Theauthorsdescribeoneofthebetterestablishednationalburdenof diseasestudies,includingfoodbornediseases.
17. KumagaiY,GilmourS,OtaE,MomoseY,OnishiT,BilanoVLF, KasugaF,SekizakiT,ShibuyaK:Estimatingtheburdenof foodbornediseasesinJapan.BullWorldHealthOrgan2015, 93:540-549C.
18. PiresSM,JakobsenLS,Ellis-IversenJ,PessoaJ,EthelbergS:
Burdenofdiseaseestimatesofsevenpathogenscommonly transmittedthroughfoodsinDenmark,2017.Foodborne PathogDis2019,17http://dx.doi.org/10.1089/fpd.2019.2705.
19. NissenJ,JokelainenP,StensvoldCR,TrevisanC,FuchsJ, BurgdorfKS,NielsenHV,PiresSM:Thediseaseburdenof congenitaltoxoplasmosisinDenmark,2014.PLoSOne2017, 12.
20. MaertensdeNoordhoutC,DevleesschauwerB,HaagsmaJA, HavelaarAH,BertrandS,VandenbergO,QuoilinS,BrandtPT, SpeybroeckN:Burdenofsalmonellosis,campylobacteriosis andlisteriosis:atimeseriesanalysis,Belgium,2012to2020.
Eurosurveillance2017,22.
21. ScallanE,HoekstraRM,MahonBE,JonesTF,GriffinPM:An assessmentofthehumanhealthimpactofsevenleading foodbornepathogensintheUnitedStatesusingdisability adjustedlifeyears.EpidemiolInfect2015,143:2795-2804.
22. SsemandaJN,ReijMW,BagabeMC,MuvunyiCM,NyamusoreJ, JoostenH,ZwieteringMH:Estimatesoftheburdenofillnesses relatedtofoodbornepathogensasfromthesyndromic surveillancedataof2013inRwanda.MicrobRiskAnal2018, 9:55-63.
23. EtienneCF:SupplementonCaribbeanburdenofillnessstudy.
JHealPopulNutr2013,31.
24. JakobsenLS,GranbyK,KnudsenVK,NautaM,PiresSM, PoulsenM:Burdenofdiseaseofdietaryexposureto acrylamideinDenmark.FoodChemToxicol2016,90:151-159.
25. LacknerJ,WeissM,Mu¨ller-GrafC,GreinerM:Diseaseburdenof methylmercuryintheGermanbirthcohort2014.PLoSOne 2018,13:e0190409.
26. Assunc¸a˜oR,MartinsC,ViegasS,ViegasC,JakobsenLS,PiresS, AlvitoP:Climatechangeandthehealthimpactofaflatoxins exposureinPortugal–anoverview.FoodAdditContamPartA 2018,35:1610-1621.
27. KirkMD,PiresSM,BlackRE,CaipoM,CrumpJA,
DevleesschauwerB,Do¨pferD,FazilA,Fischer-WalkerCL,HaldT etal.:WorldHealthOrganizationestimatesoftheglobaland regionaldiseaseburdenof22foodbornebacterial,protozoal, andviraldiseases,2010:adatasynthesis.PLoSMed2015, 12:1-21
ThestudydescribestheWHO’sworkonsupportingcountry-levelburden offoodbornediseasestudiesasapartoftheFoodborneDiseaseBurden EpidemiologyReferenceGroup,whichpublishedtheGlobalBurdenof FoodborneDiseaseestimates.Theauthorsdescribetheimportantcom- ponents and obstacles to implementing national studies in different settings.
28. DevleesschauwerB,HaagsmaJA,AnguloFJ,BellingerDC, ColeD,Do¨pferD,FazilA,Fe`vreEM,GibbHJ,HaldTetal.:
MethodologicalframeworkforWorldHealthOrganization estimatesoftheglobalburdenoffoodbornedisease.PLoS One2015,10:1-20.
29. HavelaarAH,KirkMD,TorgersonPR,GibbHJ,HaldT,LakeRJ, PraetN,BellingerDC,deSilvaNR,GargouriNetal.:WorldHealth Organizationglobalestimatesandregionalcomparisonsof theburdenoffoodbornediseasein2010.PLoSMed2015,12.
30. PhalkeyRK,YamamotoS,AwateP,MarxM:Challengeswiththe implementationofanIntegratedDiseaseSurveillanceand Response(IDSR)system:systematicreviewofthelessons learned.HealthPolicyPlan2015,30:131-143.
31. LakeRJ,DevleesschauwerB,NasinyamaG,HavelaarAH, Kuchenmu¨llerT,HaagsmaJA,JensenHH,JessaniN,De NoordhoutCM,AnguloFJetal.:Nationalstudiesasa componentoftheWorldHealthOrganizationinitiativeto estimatetheglobalandregionalburdenoffoodbornedisease.
PLoSOne2015,10:1-10.
32. WHO: FirstFormalMeetingoftheFoodborneDiseaseBurden EpidemiologyReferenceGroup(FERG):ImplementingStrategy, SettingPrioritiesAndAssigningTheTasks.2008.
33. DestaBN,GobenaT,MacuamuleC,FayemiOE,AyolabiCI, MmbagaBT,ThomasKM,DoddW,PiresSM,MajowiczSEetal.:
PracticalitiesofImplementingBurdenofDiseaseResearchin Africa:LessonsfromaPopulationSurveyComponentofOurMulti- PartnerFOCALResearchProject..Submittedforpublication 2020.
34. PiresSM,Fischer-WalkerCL,LanataCF,DevleesschauwerB, HallAJ,KirkMD,DuarteASR,BlackRE,AnguloFJ:Aetiology- specificestimatesoftheglobalandregionalincidenceand mortalityofdiarrhoealdiseasescommonlytransmitted throughfood.PLoSOne2015,10:1-17.
35. LanataCF,Fischer-WalkerCL,OlascoagaAC,TorresCX, AryeeMJ,BlackRE,ChildHealthEpidemiologyReferenceGroup oftheWorldHealthOrganizationandUNICEF:Globalcausesof diarrhealdiseasemortalityinchildren&5yearsofage:a systematicreview.PLoSOne2013,8:e72788.
36. FischerWalkerCL,SackD,BlackRE:Etiologyofdiarrheain olderchildren,adolescentsandadults:asystematicreview.
PLoSNeglTropDis2010,4:e768.
37. Anonymous:FOCAL-FoodborneDiseaseEpidemiology, SurveillanceandControlinAfricanLMIC.Agriculture,Nutrition&
HealthAcademy;2019.
38. HavelaarAH,GalindoAV,KurowickaD,CookeRM:Attributionof foodbornepathogensusingstructuredexpertelicitation.
FoodbornePathogDis2008,5:649-659.
39. MangenMJ,FriesemaIHM,PijnackerR,MughiniGrasL,Van PeltW:DiseaseBurdenofFood-RelatedPathogensinthe Netherlands,2017.2018.
40. LagerweijEGR,PijnackerR,FriesemaIHM,MughiniGrasL:
DiseaseBurdenofFood-RelatedPathogensintheNetherlands, 2019.2020.
41. SwartAN,MangenM-JJ,HavelaarAH:MicrobiologicalCriteriaas aDecisionToolforControllingCampylobacterintheBroilerMeat Chain.2013.
42. PiresSM:BurdenofDiseaseofFoodbornePathogensinDenmark.
2014.
43. Anonymous:AnnualReportonZoonosesinDenmark2016.Natl FoodInstitute,TechUnivDenmark;2017.
44. HaldT,AspinallW,DevleesschauwerB,CookeR,CorriganT, HavelaarAH,GibbHJ,TorgersonPR,KirkMD,AnguloFJetal.:
WorldHealthOrganizationestimatesoftherelative contributionsoffoodtotheburdenofdiseaseduetoselected foodbornehazards:astructuredexpertelicitation.PLoSOne 2016,11:1-35.
45. MollaL: BurdenofFoodborneDisease:PilotStudyinAlbania.
FAO/WHO/WTOInternationalForumonFoodSafetyandTrade;
Geneva,23-24April2019:2019.
46. WHO: WorkshopReport:NationalWorkshoponFoodborne DiseaseSurveillanceandResponse;HaiPhong,Vietnam,9-11 August2016:2016.
47. WHA: SeventyThirdWorldHealthAssembly(WHA73.5).Agenda Item15.3.StrengtheningEffortsonFoodSafety;3August2020:
2020.
48. AbbafatiC,MachadoDB,CislaghiB,SalmanOM,KaranikolosM, McKeeM,AbbasKM,BradyOJ,LarsonHJ,Trias-Llimo´sSetal.:
Fiveinsightsfromtheglobalburdenofdiseasestudy2019.
Lancet2020,396:1135-1159.
49. RushtonJ,BruceM,BelletC,TorgersonP,ShawA,MarshT, PigottD,StoneM,PintoJ,MesenhowskiSetal.:Initiationof globalburdenofanimaldiseasesprogramme.Lancet2018, 392:538-540.
