Burdenoffbd PDF

Globally, billions of people are at risk of foodborne diseases (FBDs) and millions
fall ill from these every year. Many die as a result of consuming unsafe food. FBDs
can also affect economic development through the tourism, agricultural and
food export industries. The South-East Asia Region has the second highest
burden of FBDs after the African Region, with more than 150 million cases and
175 000 deaths annually.
The World Health Organization has launched a comprehensive and first of

its kind report to estimate the global and regional burden of FBDs. This report will
support policy-makers in implementing the right strategies to prevent, detect and
manage foodborne risks to improve food safety. It highlights the work of WHO's
Regional Office for South-East Asia with national governments on improving
surveillance of foodborne diseases and meeting unique local challenges.
Burden of
foodborne diseases
in the South-East Asia Region
ISBN 978-92-9022-503-4
World Health House

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Burden of foodborne diseases
WHO Library Cataloguing-in-Publication data
World Health Organization, Regional Office for South-East Asia.
Burden of foodborne diseases in the South-East Asia Region.
1. Foodborne Diseases 2. Epidemiology 3. Food contamination
ISBN 978-92-9022-503-4 (NLM classification: WC 268)
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Printed in India
Contents
Acronyms................................................................................................................ v
Introduction: Foodborne diseases ...........................................................................1

Foodborne infections...................................................................................................2
Chemicals and toxins in food.......................................................................................3
Food allergy ................................................................................................................4
Global burden of foodborne diseases ......................................................................5

Objectives...................................................................................................................5
Methodology...............................................................................................................6
Gaps and limitations....................................................................................................9
Foodborne diseases in the WHO South-East Asia Region.......................................11

Foodborne diseases in under-five children.................................................................13
Conclusions and action points................................................................................17
Annexes
1. Classification of foodborne diseases...............................................................21
2 A guide to national burden of foodborne disease study..................................42
3 Categorization of subgroups under WHO regions..........................................47
iii
Burden 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
v
Introduction: Foodborne diseases
Food is an essential requirement for humans but it can also be a vehicle of disease
transmission if contaminated with harmful microbes (bacteria, viruses or parasites) or
chemicals/toxins. Globally, billions of people are at risk of foodborne diseases (FBDs)
and millions fall ill every year. Many also die as a result of consuming unsafe food.
Foodborne illnesses are mainly caused due to food contamination with harmful
bacteria, viruses, parasites, toxins or chemicals. Microbial and chemical risks could
be introduced at the farm level (e.g. using water contaminated by industrial waste
or poultry farm waste for irrigation of crops). Similarly, such risks may emerge during
processing, transportation or storage of food and food products.
While many FBDs may be self-limiting, some can be very serious and even result
in death. These diseases may be more serious in children, pregnant women and those
who are older or have a weakened immune system. Children who survive some of
the more serious FBDs may suffer from delayed physical and mental development,
impacting their quality of life permanently. Food allergy is another emerging problem.
A brief description of major FBDs of public health importance is presented in Annex 1.
FBDs are more critical in developing countries due to various reasons, such as use
of unsafe water for cleaning and processing of food, poor food production processes
and food handling, absence of adequate food storage infrastructure, and inadequate
or poorly enforced regulatory standards. The tropical climate in many countries in the
Region also favours the proliferation of pests and naturally occurring toxins and increase
the risk of contracting parasitic diseases including worm infestations.
FBDs can also affect economic development through the tourism, agriculture
and food export industries. In a globalized world, FBDs do not recognize borders. A
local incident can quickly become an international emergency due to the speed and
range of product distribution, impacting health, international relations and trade. A
brief description of foodborne diseases is presented in Annex 1.
1
Foodborne infections
When certain disease-causing microbes (bacteria, viruses or parasites) contaminate
food, they can cause foodborne illness, often called “food poisoning”. Foods that are
contaminated may not look, taste or smell any different from foods that are safe to eat.
Salmonella, Campylobacter, Shigella and Escherichia coli (also called E. coli) are the
common bacteria that cause foodborne illnesses. Salmonella is the most common cause
of foodborne illnesses and meat, egg and seafood are common food sources for much
illnesses. Some foodborne bacteria like Listeria monocytogenes can even grow inside
the refrigerator in ready-to-eat food. Staphylococcus aureus bacteria grow in food and
produce toxins that cause staphylococcal food poisoning. Viruses that commonly cause
foodborne illnesses are norovirus and hepatitis A virus (HAV), which can be transmitted
through contaminated water as well as contaminated surfaces.
Foodborne bacteria are often naturally present in food and under the right
conditions, a single bacterium can grow into millions of bacteria in a few hours. These
bacteria multiply rapidly on foods with lots of protein or carbohydrates when food
temperature is between 5 °C and 60 °C, which is often known as the “food danger
zone”. Therefore, most foodborne illnesses and outbreaks are reported during the
summer months.
Bacteria grow and multiply on some types of food more easily than on others. The
types of foods that bacteria prefer include meat, poultry, dairy products, eggs, seafood,
cooked rice, prepared fruit and salads. These foods are more likely to be infected by
foodborne bacteria but other foods could also be infected or cross-contaminated by
them if appropriate food safety measures are not taken during preparation, storage,
transportation and handling .
The symptoms of FBDs range from mild and self-limiting (nausea, vomiting and
diarrhoea with or without blood) to debilitating and life-threatening (such as kidney
and liver failure, brain and neural disorders, paralysis and potentially cancers) leading
to long periods of absenteeism from work and premature death. After eating tainted
food, abdominal cramps, diarrhoea and vomiting can start as early as one hour or
within three days depending on the foodborne pathogen, type of toxin and level of
food contamination.
2
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,
3
these toxins are not destroyed by normal cooking or processing. Naturally occurring
cyanogenic glycosides are found in raw or unprocessed cassava (Manihot esculenta),
which can cause nerve damage or death if consumed in quantity.
Food poisoning from the consumption of poisonous wild mushrooms has been
reported frequently during the monsoon season in countries of the South-East Asia
Region. In some episodes, whole families have lost their lives due to consumption of
poisonous wild mushrooms. The majority of fatal mushroom poisoning occurs due to
ingestion of Amanita phalloides – the death cap – due to its high content of Amatoxin, a
potent cytotoxin. Fatal poisoning is usually associated with delayed onset of symptoms,
which are very severe and have a toxic effect on the liver, kidney and nervous system.
Unfortunately, cases remain undiagnosed, under-reported and unpublished as these
happen in rural communities.
Food allergy
Food allergy is an abnormal response to a food triggered by the body’s immune system.
Individuals with food allergies develop symptoms by eating foods that for the vast
majority of the population are part of a healthy diet. Food allergy is a growing problem.
The prevalence of food allergies in the general population has been roughly estimated
to be around 1–3% in adults and 4–6% in children.
Peanut or groundnut allergy occurs early in life (<five years of age) and is believed
to be lifelong. Egg and milk allergies are most common food allergies among infants but
are often outgrown. More than 70 foods have been described as causing food allergies.
Several studies indicate that 75% of allergic reactions among children are due to a
limited number of foods, namely egg, peanuts, milk, fish and nuts. Fruits, vegetables,
nuts and peanuts are responsible for most allergic reactions among adults.
Food allergies are a concern for both the allergic individual and also all involved
in supplying and preparing food, including family and friends, caterers, restaurants
and the food industry. There is no cure for food allergies, so it is important to avoid
the food that cause the allergy. Having the correct information to eat, order food and
shop wisely can make a big difference. People with food allergies have to be extremely
careful about what they eat. Eating away from home is often risky for an allergic person.
Food allergic individuals need to know what to avoid eating. They are dependent
on reliable and easy-to-find information about the ingredients of the foods they buy.
Food labelling is, therefore, very important to those with food allergies as there can be
potentially serious consequences.
4
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;
5
•• provide estimates on the global burden of FBDs according to age, sex and
regions for a defined list of causative agents of microbial, parasitic and
chemical origin;
•• increase awareness and commitment among Member States for the
implementation of food safety standards; and
•• encourage Member States to use burden of foodborne disease estimates for
cost-effective analyses of prevention, intervention and control measures.
Methodology
These objectives were addressed through the establishment of six task forces, each
pursuing on groups of hazards or select aspects of the methodology. Together with the
WHO Secretariat, these task forces commissioned systematic reviews and other studies
to provide the data from which burden estimates could be calculated.
According to WHO, it was important to provide estimates of foodborne disease

at as localized a level as possible because not all foodborne hazards affect every
country equally. On account of gaps in the information available from certain countries
(especially developing countries), subregional estimates are considered more robust as
they build on the data from several countries in each Region.
The six WHO regions were divided into 14 subregions as shown in Figure 1, based
on five categories considering child and adult mortality rates, as follows:
•• 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
6
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).
7
Table 1: Hazards and foodborne diseases considered in studies
Hazards Foodborne diseases
Diarrhoeal disease Virus (1) Norovirus
agents Bacteria (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 Virus (1) Hepatitis virus A (HAV)
disease agents Bacteria (5) Brucella sp., Listeria monocytogenes,
Mycobacterium bovis (M. bovis), Salmonella
paratyphi A (S. paratyphi A), Salmonella typhi
(S. typhi)
Protozoan (1) Toxoplasma gondii
Helminths Cestodes (3) Echinococcus granulosus, Echinococcus
multilocularis, Taenia solium (T.solium)
Nematodes (2) Ascaris sp., Trichinella sp.
Trematodes (5) Clonorchis sinensis, Fasciola sp., Opisthorchis
sp., Paragonimus sp., intestinal fluke
Chemicals Toxins and poisons (3) Aflatoxin, Cassava cyanide, Dioxin
Together, the 31 hazards caused an estimated 600 million foodborne illnesses,

420 000 deaths and 33 million disability-adjusted life-years (DALY) in 2010. DALY is
a measure of the overall disease burden expressed as the number of years lost due to
ill-health, disability or early death.
Diarrhoeal diseases are the leading cause of foodborne disease illnesses –

particularly norovirus and Campylobacter spp.. It is estimated that one in 10 people
in the world fall ill every year due to eating contaminated food, as shown in Figure 2.
Foodborne diarrhoeal disease agents caused 230 000 deaths, particularly non-typhoidal
S. enterica (NTS), which causes diarrhoeal and invasive disease. Other major causes of
foodborne deaths were S. typhi, T. solium, hepatitis A virus and aflatoxin.
8
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.
9
WHO is focusing its efforts on supporting national policy-makers and governments
in improving surveillance of FBDs to obtain a clearer picture of the unique local
challenges and implement the right strategies to prevent, detect and manage foodborne
risks.
The report prepared by the WHO Foodborne Disease Burden Epidemiology

Reference Group provides the first estimates of global foodborne disease in terms of
incidence, mortality and disease burden in the form of DALY. This report is the outcome
of 10 years of monumental work by WHO and its donors and partners as well as a
number of individuals contributing to this initiative from around the world. The report
is an essential part of WHO’s efforts to facilitate global prevention, detection and
response to public health threats associated with unsafe food. It is a continuation of
WHO activities dedicated to driving food safety as highlighted during World Health
Day 2015.
An important goal of the FERG initiative and the next step in the process is to
encourage and support countries in undertaking foodborne burden of disease studies,
using consistent WHO tools and processes. Therefore, a guide to national burden of
foodborne diseases study has been briefly mentioned in Annex 2.
10
Foodborne diseases in the WHO
South-East Asia Region
Home to a quarter of the world’s population, the WHO South-East Asia Region has
the second highest burden of FBDs per population among WHO regions. It has more
than half of the global infections and deaths due to typhoid fever or hepatitis A.
Based on data (2010) from the FERG report, the annual burden of FBDs in the
South-East Asia Region includes more than:
•• 150 million illnesses
•• 175 000 deaths
•• 12 million DALYs.
Figure 3: Top 10 causes of foodborne illnesses in the WHO South-East Asia Region
Campylobacter species
Shigella species
Enterotoxigenic E. coli
Non-typhoidal S. enterica
Norovirus
Enteropathogenic E. coli
Hepatitis A virus
Entamoeba histolytica
Ascaris species
Salmonella typhi
0 5 million 10 million 15 million 20 million 25 million
11
As shown in Figure 3, Campylobacter sp. was the leading cause of foodborne illness
with an estimated more than 20 million cases every year in the Region. This was followed
by Shigella sp. and enterotoxigenic Escherichia coli with more than 19 million cases
each. At the fourth spot, NTS was estimated to cause more than 16 million infections.
In aggregate terms, E. coli and S. spp. were the leading causes of foodborne
illnesses. Norovirus and hepatitis A virus also caused significant diseases in the Region.
Amoebiasis caused by Entamoeba histolytica and worm infestation by Ascaris sp. were
the leading parasitic causes of illness due to contaminated food.
Figure 4: Top 10 causes of deaths due to foodborne illnesses in

the WHO South-East Asia Region
Salmonella typhi
Norovirus
Hepatitis A virus
Vibrio cholerae
Salmonella paratyphi A
Taenia solium
Campylobacter spp.
0 5 000 10 000 15 000 20 000 25 000 30 000 35 000
As shown in Figure 4, the leading cause of death due to foodborne diseases in

the Region was S. typhi (more than 32 000 deaths), followed by norovirus (nearly
19 000 deaths) and hepatitis A virus (nearly 18 000 deaths) respectively. NTS at fourth
position was responsible for nearly 16 000 deaths in the Region. EPEC and ETEC caused
more than 15 000 and 10 000 deaths respectively. Cholera (caused by V. cholerae) and
paratyphoid fever (caused by S. paratyphi A) were estimated to have caused more than
7600 and nearly 7500 deaths respectively.
Among the parasites, the pork tapeworm (T. solium) was estimated to cause more
than 6800 deaths annually. Despite being the leading cause of foodborne illness in the
Region, Campylobacter sp. caused only 6700 deaths here.
12
Going by the estimated burden of FBDs in terms of DALYs in the Region as shown
in Figure 5, S. typhi is the leading cause of ill-health, disability or early death and leads
to the highest number of DALYs (nearly 2.3 million). S. paratyphi A that causes a similar
illness was also estimated to be responsible for more than half a million DALYs every year.
Figure 5: Top 10 causes of DALYs due to foodborne illnesses in the

WHO South-East Asia Region
Salmonella typhi
Norovirus
Hepatitis A virus
Taenia solium
Campylobacter spp.
Vibrio cholerae
0 0.5 million 1 million 1.5 million 2 million 2.5 million
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.
13
Figure 6: Under-five children suffering from diarrhoea in the
WHO South-East Asia Region
3 in 10 children under five years of age suffer from diarrhoea

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
Campylobacter spp.
Shigella spp.
Norovirus
Ascaris spp.
Giardia spp.
Hepatitis A virus
Entamoeba histolytica
0 2 million 4 million 6 million 8 million 10 million 12 million
In children under five years of age (as shown in Figure 7), the top three causes of
foodborne illnesses were ETEC (nearly 11 million cases), EPEC (nearly 7.3 million cases)
and Campylobacter sp. (nearly 7 million cases).
Shigella sp., norovirus and NTS caused 5.2, 5 and 4.4 million illnesses respectively
and hepatitis A virus caused nearly 1.4 million cases in children under five years of age.
Among parasitic infections in under-five children, round worm (Ascaris sp.),

giardiasis (Giardia sp.) and amoebiasis (Entamoeba histolytica) caused nearly 3, 1.8 and
1 million illnesses respectively.
14
Figure 8: Top 10 causes of deaths due to foodborne illnesses in children under five
years of age in the South-East Asia Region
Salmonella typhi
Norovirus
Campylobacter spp.
Hepatitis A virus
Shigella spp.
Taenia solium
0 1 000 2 000 3 000 4 000 5 000 6 000 7 000 8 000
Source: FERG report (2015)
As shown in Figure 8, the top three causes of death due to FBDs in children
under five years of age in the Region were EPEC (nearly 7400), S. typhi (6600) and
norovirus (4000).
Other major causes of death in children under five years of age were estimated
to be NTS (3663 deaths), ETEC (3532 deaths), Campylobacter spp. (3322 deaths) and
hepatitis A virus (2805 deaths).
Figure 9: Top 10 causes of DALYs due to foodborne illnesses in children under five
years of age in the South-East Asia Region
Salmonella typhi
Norovirus
Campylobacter spp.
Hepatitis A virus
Shigella spp.
Dioxin
Ascaris spp.
0 100 000 200 000 300 000 400 000 500 000 600 000 700 000 800 000
Source: FERG report (2015)
15
In terms of DALY due to FBDs in children under five years of age (as shown in
Figure 9), the leading cause was EPEC (nearly 674 000 DALY), followed by S. typhi
(610 000 DALY) and norovirus (nearly 364 000 DALY).
Other causes of DALYs include NTS, ETEC, Campylobacter sp. hepatitis A virus,
Shigella sp. and dioxin. Interestingly, dioxin was estimated to have a significant impact
in children under five years of age in the Region with more than 160 000 DALYs. It
was based on the result of breast milk testing for a persistent organic pollutants (POPs)
study carried out in India under the Global Environmental Monitoring System (GEMS).
16
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
17
economic growth, full and productive employment and decent work for all) will also
be cited through promoting the safety of food supply domestically and internationally.
The report also reinforces the need for governments, the food industry and
individuals to do more to make food safe and prevent foodborne illnesses and
intoxications. Safe drinking water, good hygienic practices and improved sanitation
are keys for preventing foodborne illnesses and intoxications.
The majority of FBDs and deaths are preventable. Food safety is a public health
priority and governments should develop policies and regulatory frameworks to establish
and implement effective food safety systems. Food safety systems should ensure that
food producers and suppliers along the whole food chain operate responsibly and
supply safe food to consumers.
Food safety is a shared responsibility. All food operators and consumers should
understand the roles they must play to protect their health and that of the wider
community. All stakeholders can contribute to improvements in food safety throughout
the food chain by incorporating these estimates into policy development at the national
and international levels.
Think globally, act locally: while there is no single, global solution to the problem
of FBDs, a strengthened food safety system in one country will positively impact the
safety of food in other countries. There is need for coordinated, cross-border action
across the entire food supply chain.
Coordinated action at the global, regional and national levels is needed to address
risks of FBDs and ensure food safety. Education and training are needed on prevention
of FBDs among food producers, suppliers, handlers and the general public, including
women and school children.
Key action points towards ensuring food safety in the Region include the conduct
of national studies on the burden of FBDs, strengthening of laboratory capacity to be
able to detect FBDs, and strengthening the surveillance of FBDs, including the collation
of local data to validate regional estimates and translation of estimates of FBDs into
food safety policy.
The International Health Regulations (IHR 2005) is a legally binding instrument to

ensure global health security. It calls upon WHO Member States to build core capacities
for implementation of IHR (2005), including food safety events. The evaluation of IHR
self-assessment done by 11 Member States of the WHO South-East Asia Region in
18
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.
19
(4) Keep food at safe temperatures
–– refrigerate cooked food within two hours of preparation.
–– never defrost food at room temperature; defrost frozen food in the
refrigerator, cold water or the microwave.
(5) Use safe water and raw materials
–– use safe drinking water for food preparation.
–– check use-by dates and labels while buying packed food.
20
Annex 1
Classification of foodborne diseases1
2
Etiologic agent or Incubation Signs and Specimens to
Disease Food implicated Contributing factors
cause period (latency) symptoms be obtained
1. Initial or major signs and symptoms of the upper digestive tracts (nausea, vomiting)
1.1 Incubation period tends to be less than 1 hour
Fungal agents
Poisoning by Possibly resin-type From 30 minutes Nausea, vomiting, Many varieties of Vomit Ingestion of unknown
mushrooms of the substances found to 2 hours retching, diarrhoea, wild mushrooms toxic varieties of
group that causes in some types of abdominal pains mushrooms, through
gastrointestinal irritation mushrooms confusion with other
edible varieties
Chemical agents
Antimony poisoning Antimony in From a few Vomiting, abdominal Very acid food and Vomit, stool and Use of utensils that
enamelled iron minutes to 1 hour pains, diarrhoea beverages urine contain antimony,
utensils storage of very acid
food in enamelled iron
utensils
Cadmium poisoning Cadmium in plated From 15 to 30 Nausea, vomiting, Very acid foods Vomit, stool, Use of utensils that
utensils minutes abdominal pains, and drinks, candies urine and blood contain cadmium,
diarrhoea, shock and other cake storage of very acid
decorations food in containers that
contain cadmium,
ingestion of foods that
contain cadmium
1 Adapted and modified from Instituto Panamericano de Protección de Alimentos y Zoonosis (INPPAZ) – Pan American Health Organization WHO
2 Samples should be collected from any of the listed foods that have been ingested during the incubation period of the disease.

21
22
Copper poisoning Copper in pipes From a few Metallic taste, Very acid food and Vomit, gastric Storage of very acid
and utensils minutes to a few nausea, vomiting beverages lavage, urine and food in copper utensils
hours (green vomit), blood or use of copper tubing
abdominal pains, in serving very acid
diarrhoea beverages, defective
valves on devices
to prevent reflux (in
dispensers)
Fluoride poisoning Sodium fluoride in From a few Salty or soapy Any accidentally Vomit and gastric Storage of insecticides in
(fluorosis) insecticides minutes to 2 hours taste, numbness contaminated lavages the same place as food,
in the mouth, food, particularly confusion of pesticides
vomiting, diarrhoea, dry food such as with powdered foods
abdominal pains, powdered milk,
pallour, cyanosis, flour, baking
dilated pupils, powder and cake
spasms, collapse, mixes
shock

Lead poisoning Lead contained in 30 minutes or Metallic taste, Very acid food Vomit, gastric Use of vessels containing
earthenware pots, more burning in the and beverages lavages, stool, lead, storage of very
pesticides, paints, mouth, abdominal stored in vessels blood and urine acid food in vessels
plaster and putty pains, milky vomit, containing lead, containing lead, storage
black stool or any accidentally of pesticides in the same
presence of blood, contaminated food place as food
bad breath, shock,
blue line at the edge
of gums ("lead line")
Tin poisoning Tin in tin cans From 30 minutes Swelling, nausea, Very acid foods and Vomiting, stool, Storage of acid foods in
to 2 hours vomiting, abdominal beverages urine and blood unlined tin containers
pains, diarrhoea,
headache
Zinc poisoning Zinc in galvanized From a few Mouth and Very acid food and Vomit, gastric Storage of very acid food
containers minutes to 2 hours abdominal pains, beverages lavages, urine, in galvanized tins
nausea, vomiting, blood and stool
dizziness
1.2 Incubation period of 1 to 6 hours
Bacterial agents
Bacillus cereus Exoenterotoxin of From ½ to 5 hours Nausea, vomiting, Cooked or fried Vomit and stool Storage of cooked food
gastroenteritis (type B. cereus occasionally rice and plates of at warm temperatures,
emetic) diarrhoea rice with meat food cooked in large
containers, food
prepared several hours
before serving
Staphylococcal food Exoenterotoxins From 1 to 8 hours, Nausea, vomiting, Ham, beef or Patient: vomit, Inadequate refrigeration,
poisoning A, B, C, D and E average of 2 to 4 retching, abdominal poultry products, stool, rectal swab. handler touched cooked
of Staphylococcus hours pains, diarrhoea, cream-filled Carrier: nasal food, preparation of
aureus. prostration pastries, food mixes swabs, swabs food several hours
Staphylococci from and leftover food from lesion, and before serving,
the nose, skin, and rectal swabs handlers with purulent
lesions of infected infections, food kept
people and animals, at warm temperatures
and infected udders (bacterial incubation),
of cows fermentation of foods
abnormally low in acids
Chemical agents 3
Nitrite poisoning Nitrites or nitrates From 1 to 2 hours Nausea, vomiting, Cured meats, Blood Use of excessive quantities
used as compounds cyanosis, headache, any accidentally of nitrites or nitrates to
to cure meat, or dizziness, contaminated cure food or conceal
water from shallow weakness, loss of food and exposure spoilage, confusion of
wells consciousness, to excessive nitrites with common salt,
chocolate-coloured nitrification and other condiments,
blood inadequate refrigeration,
excessive nitrification in
fertilized food
3 Carbon monoxide poisoning can resemble some of the diseases included in this category. Patients who have been inside a closed automobile with the motor running or who have been in heated rooms with poor

ventilation are at risk of exposure to carbon monoxide.
23
24
Diarrheal shellfish Okadaico acid From 1/2 to 12 Diarrhoea, nausea, Mussels, clams, Gastric rinse Shellfish caught in water
poisoning (DSP) and other toxins hours, usually 4 abdominal pains oysters with high concentration
produced by hours of Dynophysis spp.
dinoflagellates of
the Dinophysis spp.
1.3 Incubation period usually from 7 to 12 hours
Fungal agents
Poisoning caused by Cyclopeptides From 6 to 24 Abdominal pains, Amanita phalloides, Urine, blood, Ingestion of certain
mushrooms of the and gyromitrine hours feeling of fullness, A. verna, Galerina vomit spp. of Amanita,
cyclopeptide and found in certain vomiting, prolonged autumnalis. Galerina and Giromitra
Giromitra groups mushrooms diarrhoea, loss Esculenta giromitra mushrooms, ingestion
of strength, (false colmenilla) of unknown varieties of
thirst, muscle and similar spp. of mushrooms, confusion
cramps, rapid mushrooms of toxic mushrooms with
and weak pulse, edible varieties
collapse, jaundice,

somnolence, dilated
pupils, coma, death
Viral agent
Norovirus (Norwalk-like Norovirus viruses 12 to 48 hours Vomiting, watery, Contaminated food Stool specimens Direct person-to-person
viruses) are relatively stable non-bloody or water taken within spread or faecally
in the environment diarrhoea with 48 to 72 hours contaminated food or
and can survive abdominal cramps, after onset of water, touching surfaces
freezing and heating low-grade fever, symptoms or objects contaminated
to 60°C myalgia, malaise, with norovirus,
headache noroviruses can also
spread via a droplet
route from vomitus.
Small round viruses, Includes ½ to 3 days, Nausea, vomiting, Shellfish from Stool, blood Infected people who
productive of adenovirus, usually 36 hours diarrhoea, contaminated water in acute and touch food ready for
gastroenteritis coronavirus, abdominal pain, convalescent consumption, harvest
rotavirus, myalgia, headache, phases of shellfish from
parvovirus, and light fever. Duration: contaminated waters,
astrovirus 36 hours improper disposal
of wastes, use of
contaminated water
2. Manifestation of pharyngitis and respiratory signs and symptoms
2.1 Incubation period less than 1 hour
Chemical agents
Calcium chloride Freezing mixtures of A few minutes Burning in the Frozen desserts Vomit Contamination of
poisoning calcium chloride for tongue, mouth, and popsicles during
freezing desserts throat, vomiting freezing, permitting the
introduction of calcium
chloride in the syrup
Sodium hydroxide Sodium hydroxide A few minutes Burning of the lips, Bottled beverages Vomit Improper rinsing of
poisoning (caustic soda) in mouth and throat; bottles washed with
compounds used vomiting, abdominal caustic substances
to wash bottles, pains, diarrhoea
detergent, drain
cleaners, hair-
relaxants
2.2 Incubation period from 18 to 72 hours
Bacterial agents
Infections by beta- Streptococcus From 1 to 3 days Pharyngitis, fever, Raw milk, foods Pharyngeal swabs, Workers who touched
haemolytic streptococci pyogenes of the nausea, vomiting, containing egg vomit cooked food, workers
throat and lesions of rhinorrhoea, with purulent infections,
infected people sometimes rash inadequate refrigeration,
improper cooking or
reheating, preparation
of food several hours

before serving
25
26
2.3 Incubation period from 3 to 30 days
Rickettsial agent
Q Fever Coxiella burnetii 2-3 weeks (3-30 Chills, headache, Raw milk from Serum Consumption of raw
days) malaise, myalgia and infected cattle or milk, direct contact
sweets goats, direct contact with aborted materials,
with contaminated inadequate disinfection
materials and disposal of aborted
materials
3. Initial or major signs and symptoms of the lower digestive tract (abdominal pains, diarrhoea)
Bacterial agents
Gastroenteritis Exoenterotoxin of B. From 8 to 16 Nausea, abdominal Foods made Stool Inadequate refrigeration,
by Bacillus cereus cereus, organisms in hours (average of pains, diarrhoea from grains, rice, storage of food at warm
(diarrheal type) the soil 12 hours) custard, sauces, temperatures (bacterial
meatballs, sausages, incubation), preparation

cooked vegetables, of food several hours
dehydrated or before serving, improper
reconstituted reheating of leftovers
products
Gastroenteritis caused Endoenterotoxin From 8 to 22 Abdominal pains, Cooked beef or Stool Inadequate refrigeration,
by Clostridium formed during the hours (average of diarrhoea poultry, broths, storage of food at warm
perfringens sporulation of C. 10 hours) sauces and soups temperatures (bacterial
perfringens in the incubation), preparation
intestines, the of food several hours
body, in human or before serving, improper
animals faeces or in reheating of leftover
the soil food
Bacterial agents
Diarrheal diseases Aeromonas 1 to 2 days Watery diarrhoea, Fish, shellfish, Stool Contamination of food
caused by Aeromonas hydrophila abdominal pain, snails, water in sea or surface water
nausea, headache
Campylobacter Campylobacter 2 to 7 days usually Abdominal pains, Raw milk, beef Stool or rectal Drinking raw milk,
Infection jejuni between 3 and 5 diarrhoea (frequently liver, raw clams swabs, blood handling raw products,
with mucus and eating raw or
blood), headache, undercooked poultry,
myalgia, fever, inadequate cooking or
anorexia, nausea, pasteurization, cross-
vomiting. Sequellae: contamination with raw
Guillian-Barre meat
syndrome
Cholera Endoenterotoxin of From 1 to 3 days Severe, watery Raw fish and Stool Harvesting of fish and
V. cholerae classical diarrhoea (rice water shellfish, food shellfish from water
and El Tor biotypes, stools), vomiting, washed or contaminated with
from faeces of abdominal pains, prepared with sewage in endemic
infected persons dehydration, thirst, contaminated areas, poor personal
collapse, loss of water, water hygiene, infected
skin tone, shrivelled handlers who touched
fingers, sunken eyes food, inadequate
cooking, use of
contaminated water in
washing or rinsing food,
improper disposal of
wastewater, use of waste
from latrines as fertilizer

27
28
Gastroenteritis caused Cholera like vibrio From 5 to 48 Abdominal pains, Various foods, Stool, rectal Infected handlers who
by cholera like vibrio hours, average diarrhoea, nausea, water swabs touch food, insufficient
from 10 to 24 vomiting, fever, cooling, incomplete
hours chills, headache, cooking, improper
myalgia cleaning and disinfection
of equipment
Diarrhoeal E. coli O157:H7, 1 to 10 days Watery diarrhoea Hamburger, raw Stool, rectal Hamburger made
diseases caused by O26, O111, O115, usually 2 to 5 days followed by bloody milk, sausages, swabs from meat of infected
Enterohaemorrhagic O113 diarrhoea, severe yogurt, lettuce, animals, consumption
Escherichia coli abdominal pain, water of raw meat and milk,
blood in the inadequate cooking,
urine. Sequelae: cross-contamination,
Haemolytic uremic infected people
syndrome (HUS) touching food ready for
consumption, improper
desiccation and
fermentation of meats

Diarrhoea caused Strains of ½ to 3 days Severe abdominal Salads and other Stool, rectal Inadequate cooking,
by Enteroinvasive Enteroinvasive pain, fever, watery food that are not swabs infected persons
Escherichia coli E. coli diarrhoea, (usually subsequently touching food ready
with mucus and treated, water for consumption, not
blood present) washing hands after
tenesmus defecation, storing food
at room temperature,
storing food in the
refrigerator in large
containers, preparing
food several hours
before serving, improper
reheating of food
Diarrhoea caused by Strains of ETEC ½ to 3 days Profuse watery Salads and other Stool, rectal Inadequate cooking,
ETEC diarrhoea (without food that are not swabs infected people
mucus or blood) subsequently touching food ready
abdominal thermally treated, for consumption, not
pain, vomiting, fresh cheeses, washing hands after
prostration, water defecation, storage
dehydration, light of food at room
fever temperature, keeping
food in the refrigerator
in large containers,
preparing food several
hours before serving,
improper reheating of
food, use of raw milk in
making cheese
Enteritis by Plesiomonas Pleisomonas 1 to 2 days Diarrhoea with Water Stool, rectal Inadequate cooking
shigeloides mucus and blood in swabs
the stool
Salmonellosis Various serotypes From 6 to 72 Abdominal pains, Beef and poultry Stool, rectal Inadequate refrigeration,
of Salmonella from hours, average diarrhoea, chills, and their by- swabs storage of food at
faeces of infected from 18 to 36 fever, nausea, products, egg warm temperatures
people and animals hours vomiting, malaise products, other (bacterial incubation),
foods contaminated inadequate cooking and
with salmonellae reheating, preparation
of food several hours
before serving, cross-
contamination, improper
cleaning of equipment,
infected handlers who
touch cooked food,
acquisition of food from
contaminated sources.

29
30
Shigellosis Shigella flexneri, From ½ to 7 days, Abdominal pains, Any food ready Stool, rectal Infected handlers
S. dysenteriae, S. usually from 1 to diarrhoea, mucoid for consumption swabs touching the food,
sonnei and S. boydii 3 days faeces with blood that becomes inadequate refrigeration,
present, fever contaminated, improper cooking and
frequently salads, reheating
water
Gastroenteritis caused V. parahaemolyticus From 2 to 48 Abdominal pains, Raw or Stool, rectal Inadequate cooking,
by V. parahaemolyticus from sea water or hours, average 12 diarrhoea, nausea, contaminated sea swabs inadequate refrigeration,
marine products hours vomiting, fever, food, shellfish cross-contamination,
chills, headache improper cleaning of
equipment, use of sea
water in preparing food
Diarrhoea caused by Yersinia 1 to 7 days Abdominal pains Raw milk, water Stool, rectal Inadequate cooking
yersiniosis enterocolitica (can simulate swabs or pasteurization,
appendicitis), light cross-contamination,
fever, headache, contaminated
discomfort, anorexia, ingredients or water

nausea, vomiting
Viral agents
Viral gastroenteritis Enteric viruses From 3 to 5 days Diarrhoea, fever, Food ready for Stool Poor personal hygiene,
(echovirus, vomiting, abdominal consumption infected workers
coxsackievirus, pains, sometimes touching food, improper
reovirus, respiratory cooking and reheating
adenovirus) symptoms
3.3 Incubation period from a few days to several weeks
Parasitic agents
Ascariasis Ascaris lumbricoides 14 to 20 days Stomach disorders, Vegetables and Stool Inadequate waste
cramps, vomiting, water disposal, poor hygiene in
fever food handling
Amoebic dysentery Entamoeba From a few days Abdominal pains, Vegetables and raw Stool Poor personal hygiene,
(amoebiasis) histolytica to several months constipation or fruits infected handlers
usually between 2 diarrhoea with blood touching the food,
and 4 weeks and mucus improper cooking and
reheating
Giardiasis Giardia lamblia From 1 to 6 weeks Abdominal pains, Raw fruits and Stool Poor personal hygiene,
from faeces of diarrhoea with vegetables, water infected handlers
infected people mucus, fatty stools touching food, improper
cooking, improper waste
water disposal
Cryptosporidiosis Cryptosporidium 1 to 12 days, Profuse watery Apple cider, water Stool, intestinal Improper disposal
parvum usually 7 days diarrhoea, biopsy of animal wastes,
abdominal pain, contamination from the
anorexia, vomiting, animal environment,
light fever inadequate filtering of
water
Hydatidosis (unilocular Echinococcus Months to years Abdominal pain, Food or water Biopsy or serum Consumption of raw
or multilocular) granulosus, abnormal abdominal contaminated with vegetables or water
Echinococcus tenderness, faeces of infected contaminated with
multilocularis hepatomegaly with dog, fox faeces of infected dog
an abdominal mass, or fox
jaundice, fever
Liverfluke (Fascioliasis) Fasciola hepatica From 4 to 6 weeks Dyspepsia, fever, Aquatic plants or Stool, tissue Eating raw aquatic
right upper quadrant plants with high biopsy plants, inefficient
pain, anorexia, moisture content disposal of human and
hepatomegaly, animal wastes in pond or
splenomegaly, water bodies
ascites, urticaria,
respiratory
symptoms, and
jaundice

31
32
Opisthorchiasis O. viverrine, O. From 4 to 5 weeks Flatulence, fatigue, raw or Stool Consuming raw or
felineus dyspepsia, right undercooked fish undercooked fish and
upper quadrant improper sanitary
abdominal pain, disposal of faeces
anorexia, and mild facilitate infestation of
hepatomegaly fish in ponds
Intestinal fluke Fasciolopsis buksi, 6–8 weeks Diarrhoea, Raw or Stool Consuming raw
(Fasciolopsis) Echinostoma constipation, undercooked aquatic plants, faecal
abdominal aquatic plants contamination (from
pain, dizziness, humans or pigs) of water
and headache, where aquatic plants are
sometimes vomiting, grown
fever, nausea, and
allergic reactions
such as oedema of
the face
Lung fluke Paragonimus 2–15 days Cough, fever, bloody Raw or Sputum, stool Crab or crayfish

(Paragonimiasis) westermani sputum, loss of undercooked crab consumed raw or
appetite, chest pain, or crayfish prepared only in vinegar,
and headache brine, or wine without
Chronic stage: cooking
productive cough
with brownish
sputum, chest pain,
and night sweats
Taeniasis due to Taenia T. solium from From 3 to 6 weeks General malaise, Raw or Stool Failure to inspect meat,
solium (pork tapeworm) infected pork hunger, weight loss undercooked pork improper cooking,
improper wastewater
disposal, grasses
contaminated by waste
water
Taeniasis due to T. saginata from From 8 to 14 General malaise, Raw or Stool Failure to inspect meat,
Taenia saginata (beef meat from meat of weeks hunger, weight loss, undercooked meat improper cooking,
tapeworm) infected cattle abdominal pains improper wastewater
disposal, pasture
contaminated by waste
water
Anisakiasis Anisakis From 4 to 6 weeks Stomach pain, Rock fish, herring, Stool Ingestion of raw or
pseudoterranova nausea, vomiting, cod, salmon, squid, undercooked fish
abdominal pain sushi
Diphyllobotriasis (fish Diphyllobothrium From 3 to 6 weeks Undefined Raw or Stool Inadequate cooking,
tapeworm infection) latum from flesh of gastrointestinal undercooked fresh improper wastewater
infected fish discomfort, anaemia water fish disposal, lakes
may occur contaminated by waste
water
Sparganosis Spirometra spp. painful oedema, Contaminated Biopsy Drinking water
seizures, water, consuming contaminated with
hemiparesis, and raw flesh of frog or infected copepods
headaches snake or consuming raw or
under-cooked flesh of
frog or snake
4. Manifestation of neurological signs and symptoms (visual disorders, tingling, paralysis)
4.1 Incubation period tends to be less than 1 hour
Fungal agents
Mushroom poisoning Ibotenic and From 30 to 60 Somnolence and Amanita Ingestion of Amanita
from the group that muscimol found in minutes state of intoxication, muscaria, A. muscaria and related
contains ibotenic acid certain mushrooms confusion, muscular pantherina, and spp. of mushrooms,
spasms, delirium, related spp. of ingestion of unknown
visual disorders mushrooms varieties of mushrooms,
confusion of toxic
mushrooms with edible
varieties

33
34
Poisoning caused Muscarine found in 15 minutes to a Excessive saliva- Clitocybe deal- Vomit Ingestion of A.
by mushrooms certain mushrooms few hours tion, perspiration, bata, C. rivulose, muscaria and related
of the group that lacrimation, drop and many spp. of spp., consumption
contains muscarine in blood pressure, Inocybe and Bole- of unknown varieties
(muscarinism) irregular pulse, tus mushrooms of mushrooms,
contraction of the consumption of toxic
pupils, blurred mushrooms by mistake
vision, asthmatic
breathing
Chemical agents
Organophosphorus Organophosphorus From a few Nausea, vomiting, Any accidentally Blood, urine, Spraying of crops
poisoning insecticides, such minutes to a few abdominal contaminated food adipose tissue (for immediately before
as parathion, TEPP, hours pains, diarrhoea, biopsy) harvest, storage of
diazinon, malathion headache, insecticides in the same
nervousness, blurred place as food, confusion
vision, chest pains, of pesticides with food in
cyanosis, confusion, powdered form

spasmodic
contraction,
convulsions
Carbamate poisoning Carbaryl (sevin), ½ hour Epigastric pain, Any accidentally Blood, urine Improper application
Temik (aldicarb) vomiting, abnormal contaminated food to crops, storage in the
salivation, same areas as food,
contraction of mistaken as food in
the pupils, lack powdered form
of muscular
coordination
Dinoflagellates
Paralytic Shellfish Saxitoxin and Several minutes to Tingling, burning, Mussels and clams Gastric lavage Harvesting shellfish
Poisoning other dinoflagellate 30 minutes and numbness from water with high
toxins of the spp. around the lips concentrations of
Alexandrium and and the tips of the dinoflagellates of the
Gymnodinium fingers, dizzy spells, spp. Alexandrium and
incoherent speech, Gymnodinium
respiratory paralysis
Tetrodotoxism Tetrodoxin found in From 10 minutes Sensation of Fish of the puffer Stool Ingestion of fish of
(tetraodon poisoning) the intestines and to 3 hours tingling in the fish family the puffer fish family,
gonads of puffer fish fingers and toes, consumption of such
(blowfish, globefish) dizziness, pallor, fish without extracting
numbness of the intestines and gonads
mouth and limbs,
gastrointestinal
symptoms,
haemorrhage and
flaking of the skin,
fixation of the
eyes, spasmodic
contraction,
paralysis, cyanosis
Poisonous plants
Jimsonweed (thorn Tropane alkaloids Less than 1 hour Abnormal thirst, Any part of the Urine Consumption of any
apple) poisoning found in Datura photophobia, herb, tomatoes part of the Jimson weed
stramonium distorted vision, grown with grafts or consumption of
difficulty speaking, tomatoes grown with
delirium, facial grafts
flushing, delirium,
coma, rapid pulse
heart attack.

35
36
Water hemlock Resin or cicutoxin From 15 to 60 Excessive salivation, Root of water Urine Ingestion of water
poisoning found in water minutes nausea, vomiting, hemlock (Cicuta hemlock; confusion
hemlock stomach pains, virosaand C. of the root of water
frothing at the masculata) hemlock with wild
mouth, irregular parsnip, sweet potato,
breathing, or carrot
convulsions,
respiratory paralysis
4.2 Incubation period usually between 1 and 6 hours
Chemical agents
Chlorinated Insecticides From 30 minutes Nausea, vomiting, Any accidentally Blood, urine, Storage of insecticides in
hydrocarbon poisoning containing to 6 hours paresthesia, contaminated food stool, gastric the same place as food,
chlorinated dizziness, muscular lavages confusion of pesticides
hydrocarbon, such weakness, anorexia, with food in powdered
as aldrin, chlordane, weight loss, form
DDT, dieldrin, confusion

endrin, lindane,
and toxaphene
Marine plankton
Ciguatera poisoning Ciguatoxin from From 3 to 5 hours, Tingling and Numerous varieties Ingestion of liver,
the intestines, roe, sometimes more numbness around of tropical fish intestines, roe, gonads,
gonads, and flesh of the mouth, metallic or flesh of tropical reef
tropical marine fish taste, dryness fish; in general the large
of the mouth, reef fish are more likely
gastrointestinal to be toxic
symptoms, watery
stool, myalgia,
dizziness, dilated
pupils, blurred
vision, prostration,
paralysis
Bacterial agents
Botulism Exoneurotoxins From 2 hours to 8 Vertigo, double Home-canned Blood, stool, Improper preparation
A, B, E and F days, average from or blurred vision, foods with low gastric lavage of canned food
from Clostridium 18 to 36 hours dryness of the acid content, and smoked fish,
botulinum. The mouth, difficulty in vacuum-packed uncontrolled
spores are found swallowing, speaking fish; fermented roe, fermentation
in soil and animal and breathing; fish and marine
intestines descending mammals, fish that
flaccid paralysis, have not been
constipation, gutted
dilation or fixation
of the pupils,
respiratory paralysis.
Gastrointestinal
symptoms can
precede neurological
symptoms. Is
frequently fatal
4.4 Incubation period higher than 72 hours
Chemical agents
Mercury poisoning Ethyl and methyl 1 week or more Numbness, Grains treated Urine, blood, hair Fish caught in waters
compounds weakness of the legs, with fungicides contaminated with
of mercury in spastic paralysis, that contain mercury compounds,
industrial waste and deterioration in the mercury; pork, animals fed with grains
organic mercury in vision, blindness, fish, and shellfish treated with fungicides
fungicides coma exposed to mercury containing mercury,
compounds ingestion of mercury,
ingestion of grains
treated with mercury or
meat from animals fed
with those grains

37
38
Triorthocresyl Triorthocresyl From 5 to 21 days, Gastrointestinal Cooking oils, Biopsy of the Use of the compound
phosphate poisoning phosphate used average 10 days symptoms, pains extracts and gastronemius as an extract or as oil for
as an extract or in the legs, very other foodstuffs muscle cooking or for salads
as a substitute for accentuated equine contaminated
kitchen oil gait, limpness of feet with triorthocresyl
and wrist phosphate
5. Manifestation of signs and symptoms of generalized infection (fever, chills, discomfort, pains)
5.1 Incubation period between 12-72 hours
Bacterial agents
Infection caused by Vibrio vulnificus 16 hours Septicaemia, fever, Oysters and raw Blood People with liver
Vibrio vulnificus malaise, prostration, clams problems
typical of cases
with previous liver
problems
Anthrax Bacillus anthracis From 3 to 5 days Gastroenteritis, Meat from sick Stool, vomiting Clinical manifestations

vomiting, animals after consumption of
haemorrhagic meat from sick animals
depositions
Streptococcus suis Streptococcus suis 3 hours to 14 days Headache, fever, Infected pigs or CSF or blood Direct contact with
infection vomiting, meningitis, contaminated pork samples infected or contaminated
septicaemia, materials, processing or
endocarditis, toxic consuming uncooked
shock syndrome, or partially cooked pork
arthritis, acute products
deafness
5.2 Incubation period longer than 1 week
Bacterial agents
Brucellosis Brucella abortus, B. From 7 to 21 days Fever, chills, sweats, Raw milk, goat Blood Unpasteurized milk,
melitensis, and B. weakness, malaise, cheese made with livestock infected by
suis in tissues and headache, myalgia raw milk brucellosis, contact with
milk of infected and arthralgia, aborted materials
animals weight loss
Tuberculosis Mycobacterium 4–12 weeks Lung lesions Raw milk and meat Culture from Consumption of raw
bovis basically but also in secretions or milk, consumption of
kidneys, liver, spleen tissues raw infected meat from
and corresponding domestic or wild animals
nodes
Listeria infection Listeria 3 to 70 days, Fever, headache, Milk, fresh cheese, Blood, urine Improper cooking, non-
monocytogenes usually 4 to 21 nausea, vomiting, processed meats pasteurization of milk,
days abortion, meningitis, prolonged cooling
encephalitis, and
sepsis
Typhoid and S. enterica Serotype From 7 to 28 days, Malaise, headache, Shellfish, food Stool, rectal Infected handlers
paratyphoid fever typhi found in average 14 days fever, cough, contaminated by swabs, blood touching food, poor
faeces of infected nausea, vomiting, handlers, raw milk, in early part of personal hygiene,
people, other constipation, cheese, watercress, the acute phase, improper cooking,
serotypes (as abdominal pains, water urine in the acute inadequate refrigeration,
paratyphi A, cholera chills, rose spots, phase improper wastewater
suis) for cases of bloody stool disposal, acquisition of
paratyphoid, faeces food from contaminated
of humans and sources, harvesting of
animals shellfish from waters
contaminated with
sewage

39
40
Viral agents
Hepatitis A Hepatitis A virus From 10 to 50 Fever, malaise, Shellfish, any food Stool, urine, Infected handlers
found in the faeces, days, average 25 lassitude, anorexia, contaminated with blood touching food, poor
urine, or blood of days nausea, abdominal hepatitis virus, personal hygiene,
infected people and pains, jaundice water improper cooking,
other infected non- harvesting shellfish from
human primates waters contaminated
with sewage, improper
disposal of wastewater
Hepatitis E Hepatitis E virus From 15 to 65 Similar to above Shellfish, any food Stool, urine, Infected handlers
days usually 35 (high mortality for contaminated with blood touching food, poor
to 40 pregnant women) hepatitis virus, personal hygiene,
water improper cooking,
harvesting shellfish from
waters contaminated
with sewage, improper
disposal of waste water

Parasitic agents
Angiostrongy- Angiosgtrongylus From 14 to 16 Gastroenteritis, Crabs, prawns, Blood Improper cooking
liasis (Eosinophilic cantonensis (lung- days headache, stiffness slugs, shrimp, raw
meningoencephalitis) worm of rats) found of the neck and snails
in rodent droppings back, low-grade
and the soil fever
Toxoplasmosis Toxoplasma gondii From 10 to 13 Fever, headache, Raw or Lymph nodes (for Improper cooking of
found in tissues and days myalgia, cutaneous undercooked meat biopsy), blood mutton, pork, beef or
meat of infected rash veal
animals
Trichinosis Trichinella From 4 to 28 days, Gastroenteritis, fever, Pork, bear, walrus Muscle tissue (for Ingestion of
spiralis found in average 9 days oedema around the biopsy) undercooked pork or
pork and bear meat eyes, myalgia, chills, bear meat, improper
prostration, difficulty cooking or temperatures,
breathing feeding pigs with
garbage that has not
been cooked or properly
treated with heat
6. Allergic symptoms and signs (flushing and itching of the face)
Incubation period less than 1 hour
Bacterial agents (and animals)
Scombroid poisoning Histamine- From a few Headache, dizziness, Tuna fish, blue Vomit Inadequate refrigeration
(Histamine Poisoning) like substances minutes to 1 hour nausea, vomiting, mackerel, Pacific of scombroid fish,
produced peppery taste, dolphin, cheese improper curing of
by Proteus spp. burning in the cheese
or other histidine throat, facial swelling
bacteria found in and flushing, colic,
the flesh of fish itching
Chemical agents
Monosodium glutamate Excessive quantity From a few Burning sensation in Food seasoned Use of excessive
poisoning of monosodium minutes to 1 hour the back of the neck, with monosodium quantities of
glutamate forearms and chest; glutamate monosodium glutamate
tightness, tingling, to enhance flavour. Only
facial flushing, some individuals are
dizziness, headache, sensitive to the MSG
nausea
Nicotinic acid Sodium nicotinate From a few Reddening, hot Meat or other food Use of sodium nicotinate
poisoning (niacin) used as colour minutes to an hour flashes, itching, to which sodium to preserve colour
preservative abdominal pains, nicotinate has been
swelling of the face added
and knees

41
Annex 2
A guide to national burden of foodborne disease study
The FERG’s report on the global burden of foodborne diseases highlights the worldwide
threat of FBDs and emphasizes the need for all national governments, the food industry
and individuals to work together to make food safe and prevent FBDs. The report also
highlights that action to reduce the impact, illnesses and deaths due to FBDs needs to
be adapted based on national needs as the types of food contaminants and reasons
for their prevalence differ in various regions and countries.
While there is no single, global solution to the problem of FBDs, a strengthened

food safety system in one country is likely to positively impact the food safety in other
countries. There is need for coordinated action across the entire food supply chain in
all countries. WHO is working with national governments to improve surveillance of
FBDs to obtain a clear picture of unique local challenges in all countries.
The objectives of individual country studies are to:

•• deliver burden of disease estimates in the area of FBDs;
•• contribute to strengthening the capacity of countries in conducting burden
of foodborne disease assessments, including knowledge translation capacity
development within the country; and
•• provide results that are translated into food safety policy for the country
involved.
The anticipated uses of the results from the burden of foodborne disease studies
are:
(1) prioritization of food safety as an issue within a country.
(2) prioritization of specific food safety issues within a country.
(3) provision of a baseline against which to evaluate future food safety
interventions,
(4) providing assistance with harmonization of international trade and regulatory
standards,
42
(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.
43
3. FERG priority setting tool (WHO, 2012)
This prioritization tool is intended to assist with the identification of agents relevant to the
national burden of foodborne disease study. Agents that will be addressed by the FERG
in its global and regional burden of foodborne disease studies have been categorized
into two groups: (i) global agents of importance in all countries (should be considered
by all national burden studies), and (ii) local agents, which are of importance in some
specific countries or regions, especially in the case of parasitic hazards.
The tool provides key questions to help countries in determining which foodborne
hazards are relevant for their national burden of FBDs study. The list of local agents
may be complemented by additional local agents not addressed by FERG but which
may still be relevant to the national study.
The list of priority pathogens for a specific national burden of foodborne disease
study consists of all “global” and a selection of the “local” agents addressed by FERG and
possibly complemented with other agents that are of particular relevance to the country.
4. Data sources checklist (Country Studies Task Force: WHO, 2012)
As a part of the FBDs burden protocol to be used in country studies, this guidance
document provides a checklist for participating countries to take stock of existing data
required for the national study and is intended to be an aid to data gathering. However,
it is neither comprehensive nor exhaustive.
The following information is required for a national FBDs burden study:

(1) Demographic baseline
–– Total population for the selected time period, stratified by age and sex;
–– Total number of pregnant women and the total number of live births,
stillbirths and abortions for the selected time period;
–– Local life expectancy table for the selected time period, stratified by
sex.
(2) Epidemiological data
–– 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.
44
(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.
45
6. FERG workplan matrix for the Country Study Monitoring Matrix
(WHO, 2013)
This is a matrix to assist the countries to monitor the progress of their studies and is
intended to be customized and adapted based on specific country workplans. The
country study monitoring matrix consists of two main sections: content and process of
the monitoring exercise. The content section consists of five items – activity, specific
tasks, activity leader, timelines and final deliverable/output; and the process section
consists of four items – monitoring lead, dates for monitoring and reporting, target
audience and comments.
7. National Foodborne Burden of Disease Study: final report draft

outline (FERG Country Studies Task Force; WHO, 2013)
This is a draft outline to assist countries to prepare a final report of the country study
to estimate the burden of FBDs.
46
Annex 3: Categorization of
subgroups under WHO regions
Subregion WHO Member States
AFR D Algeria; Angola; Benin; Burkina Faso; Cameroon; Cape Verde; Chad; Comoros;
Equatorial Guinea; Gabon; Gambia; Ghana; Guinea; Guinea-Bissau; Liberia;
Madagascar; Mali; Mauritania; Mauritius; Niger; Nigeria; Sao Tome and Principe;
Senegal; Seychelles; Sierra Leone; Togo.
AFR E Botswana; Burundi; Central African Republic; Congo; Côte d'Ivoire; Democratic
Republic of the Congo; Eritrea; Ethiopia; Kenya; Lesotho; Malawi; Mozambique;
Namibia; Rwanda; South Africa; Swaziland; Uganda; United Republic of
Tanzania; Zambia; Zimbabwe.
AMR A Canada; Cuba; United States of America.
AMR B Antigua and Barbuda; Argentina; Bahamas; Barbados; Belize; Brazil; Chile;
Colombia; Costa Rica; Dominica; Dominican Republic; El Salvador; Grenada;
Guyana; Honduras; Jamaica; Mexico; Panama; Paraguay; Saint Kitts and Nevis;
Saint Lucia; Saint Vincent and the Grenadines; Suriname; Trinidad and Tobago;
Uruguay; Venezuela (Bolivarian Republic of).
AMR D Bolivia (Plurinational State of); Ecuador; Guatemala; Haiti; Nicaragua; Peru.
EMR B Bahrain; Iran (Islamic Republic of); Jordan; Kuwait; Lebanon; Libyan Arab
Jamahiriya; Oman; Qatar; Saudi Arabia; Syrian Arab Republic; Tunisia; United
Arab Emirates.
EMR D Afghanistan; Djibouti; Egypt; Iraq; Morocco; Pakistan; Somalia; South Sudan;
Sudan; Yemen.
EUR A Andorra; Austria; Belgium; Croatia; Cyprus; Czech Republic; Denmark; Finland;
France; Germany; Greece; Iceland; Ireland; Israel; Italy; Luxembourg; Malta;
Monaco; Netherlands; Norway; Portugal; San Marino; Slovenia; Spain; Sweden;
Switzerland; United Kingdom.
EUR B Albania; Armenia; Azerbaijan; Bosnia and Herzegovina; Bulgaria; Georgia;
Kyrgyzstan; Montenegro; Poland; Romania; Serbia; Slovakia; Tajikistan; The
Former Yugoslav Republic of Macedonia; Turkey; Turkmenistan; Uzbekistan.
EUR C Belarus; Estonia; Hungary; Kazakhstan; Latvia; Lithuania; Republic of Moldova;
Russian Federation; Ukraine.
SEAR B Indonesia; Sri Lanka; Thailand.
SEAR D Bangladesh; Bhutan; Democratic People's Republic of Korea; India; Maldives;
Myanmar; Nepal; Timor-Leste.
WPR A Australia; Brunei Darussalam; Japan; New Zealand; Singapore.
WPR B Cambodia; China; Cook Islands; Fiji; Kiribati; Lao People's Democratic Republic;
Malaysia; Marshall Islands; Micronesia (Federated States of); Mongolia; Nauru;
Niue; Palau; Papua New Guinea; Philippines; Republic of Korea; Samoa;
Solomon Islands; Tonga; Tuvalu; Vanuatu; Viet Nam.
47
Notes:
(1) The subregions are defined on the basis of child and adult mortality as
described by Ezzati et al.4 Stratum A = very low child and adult mortality;
Stratum B = low child mortality and very low adult mortality; Stratum C =
low child mortality and high adult mortality; Stratum D = high child and
adult mortality; and Stratum E = high child mortality and very high adult
mortality. The use of the term subregion here and throughout the text does
not identify an official grouping of WHO Member States and the subregions
are not related to the six official WHO regions, which are AFR = African
Region; AMR = Region of the Americas; EMR = Eastern Mediterranean
Region; EUR = European Region; SEAR = South-East Asia Region; WPR
= Western Pacific Region.
(2) South Sudan was re-assigned to the WHO African Region in May 2013. As
this study relates to time periods prior to this date, estimates for South Sudan
were included in the WHO Eastern Mediterranean Region.
4 Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ, Comparative Risk Assessment Collabo- rating Group (2002) Selected major risk
factors and global and regional burden of disease. Lancet 360 (9343):1347–1360. PMID: 12423980.
48
Globally, billions of people are at risk of foodborne diseases (FBDs) and millions
fall ill from these every year. Many die as a result of consuming unsafe food. FBDs
can also affect economic development through the tourism, agricultural and
food export industries. The South-East Asia Region has the second highest
burden of FBDs after the African Region, with more than 150 million cases and
175 000 deaths annually.
The World Health Organization has launched a comprehensive and first of

its kind report to estimate the global and regional burden of FBDs. This report will
support policy-makers in implementing the right strategies to prevent, detect and
manage foodborne risks to improve food safety. It highlights the work of WHO's
Regional Office for South-East Asia with national governments on improving
surveillance of foodborne diseases and meeting unique local challenges.
Burden of
foodborne diseases
ISBN 978-92-9022-503-4
World Health House

Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
www.searo.who.int
9 789290 225034

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Globally, billions of people are at risk of foodborne diseases (FBDs) and millions

The World Health Organization has launched a comprehensive and first of

World Health House

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)

© World Health Organization 2016

All rights reserved.

Requests for publications, or for permission to reproduce or translate WHO publications

Introduction: Foodborne diseases ...........................................................................1

Global burden of foodborne diseases ......................................................................5

Foodborne diseases in the WHO South-East Asia Region.......................................11

Conclusions and action points................................................................................17

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

Mycotoxins are a group of naturally occurring chemicals produced by certain

According to WHO, it was important to provide estimates of foodborne disease

Source: FERG Report (2015)

Thirty-one foodborne hazards causing 32 diseases with 11 diarrhoeal disease

Together, the 31 hazards caused an estimated 600 million foodborne illnesses,

Diarrhoeal diseases are the leading cause of foodborne disease illnesses –

Gaps and limitations

The report prepared by the WHO Foodborne Disease Burden Epidemiology

0 5 million 10 million 15 million 20 million 25 million

Source: FERG Report (2015)

Figure 4: Top 10 causes of deaths due to foodborne illnesses in

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

Source: FERG Report (2015)

As shown in Figure 4, the leading cause of death due to foodborne diseases in

Figure 5: Top 10 causes of DALYs due to foodborne illnesses in the

0 0.5 million 1 million 1.5 million 2 million 2.5 million

Source: FERG Report (2015)

Interestingly, non-typhoidal S. enterica continued to occupy the fourth position

Foodborne diseases in under-five children

3 in 10 children under five years of age suffer from diarrhoea

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

Source: FERG Report (2015)

Among parasitic infections in under-five children, round worm (Ascaris sp.),

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

Source: FERG report (2015)

Source: FERG report (2015)

The International Health Regulations (IHR 2005) is a legally binding instrument to

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region

Burden of foodborne diseases in the South-East Asia Region