Perspectives

Perspectives

Diarrhoeal disease in children due to contaminated food

In December 2015, the World Health taminated food among all age groups: but there are many other factors in pre-
Organization (WHO) released esti- 687 DALYs (95% UI: 369–1106) per venting disease, including interventions
mates of the burden of human disease 100 000 population compared with 229 aimed at the food processing, service
attributable to consumption of food (95% UI: 160–323) per 100 000 globally and retail sectors.8
contaminated with 31 infectious agents and 23 (95% UI: 13–33) per 100 000 in Before the 2015 WHO report,1 the
or chemicals. 1 The report concluded North America.4 These differences sug- disease burden due to contaminated
that exposure to contaminated food gest that implementation of preventive food, and therefore the importance of
worldwide in 2010 resulted in 600 mil- measures in low- and middle-income food safety, was somewhat neglected.
lion episodes of illness (95% uncertainty countries could prevent substantial Globally, much attention has been
interval, UI: 420–960 million), 420 000 foodborne disease. Furthermore, the given to improving water and sanita-
deaths (95% UI: 310 000–600 000) and WHO disease burden estimates were tion; rightly so, as this is a vital factor
33 million disability-adjusted life years conservative, because for method- in attempts to decrease the rates of
(DALYs) (95% UI: 25–46 million).1 The ological reasons they largely excluded diarrhoeal disease due to all causes.
numbers were based on 4.6 billion cases diarrhoeal disease associated with hu- Contaminated water plays a role too in
of diarrhoea (95% UI: 3.5–6.5 billion) man immunodeficiency virus (HIV) foodborne disease when it is used in the
and 1.6 million deaths due to diarrhoea infection. It is likely that HIV-infected preparation of food. However, the lack of
(95% UI: 1.3–1.9 million) that occurred persons experience a substantial burden specific attention on the importance of
worldwide in 2010, similar to numbers of infection from contaminated food, foodborne disease has meant that gov-
occurring in later years.2 making food safety important for this ernments, industry, donors and funding
A key element of the estimation was vulnerable group. In addition, these agencies have not prioritized improving
attributing a proportion of the diarrhoea estimates have not yet captured the ef- food safety. International agencies, such
deaths to foodborne transmission of in- fects of foodborne disease or subclinical as WHO and the Food and Agriculture
fections. A structured expert judgement enteric infections on malnutrition and Organization, along with many other
was used to apportion transmission its subsequent health and development international agencies and nongovern-
modes for individual pathogens, by esti- outcomes.6 mental organizations, have a long his-
mating that 29% (95% UI: 22–36%) of 11 Globally, diarrhoeal infections with tory of working to improve food safety.
key bacterial, viral and protozoal causes Salmonella species (including invasive To have maximal effect, these efforts
of diarrhoea were foodborne.3 Food con- infections), enteropathogenic and need to be targeted at contaminated
taminated with these 11 agents resulted enterotoxigenic Escherichia coli, noro- foods and at populations at higher risk
in 548 million episodes of diarrhoea virus and Campylobacter species were of disease. To date, the majority of food
(95% UI: 370–888 million) and 200 000 responsible for the greatest burden of safety efforts have been too general and
deaths (95% UI: 137 000–287 000) in foodborne disease. Food safety measures non-specific to succeed in interrupting
2010. Of these, 217 million infections that would be effective against these en- possible disease transmission pathways.
(39%; 95% UI: 29–38%) were in chil- teric pathogens are likely to be similar, at It is likely that there is a strong correla-
dren younger than 5 years of age.4 This least at the food preparation stage. Cred- tion between food insecurity in a geo-
disproportionate burden of foodborne ible evidence to guide interventions is graphic area and the risk of foodborne
diarrhoeal disease in young children is scarce, however. Contamination of food disease (for example, if families have to
evident in the high rate ratio of DALYs can occur anywhere along the chain of eat foods that are unsafe), although this
in children younger than 5 years com- production and preparation, from where is poorly quantified.9
pared with older children and adults a food or ingredient is grown, har- The WHO estimates of the food-
(ratio: 11.6; 95% UI: 8.4–15.6). Among vested, processed, transported and sold, borne disease burden highlight the
children younger than 5 years, food- through to where it is prepared before need for attention on improved food
borne transmission of the 11 agents consumption. Hygienic preparation and safety that will specifically prevent in-
could have constituted as much as 16% storage of food in the home is particular- fections in children.10 A key strategy to
of the estimated 578 000 deaths due to ly important for young children, but so prevent foodborne infections in children
diarrhoea (95% UI: 448 000–750 000), too are systemic improvements in food younger than 6–23 months of age, who
updated to 2013.5 supplies, such as pasteurization of milk.7 have very high rates of diarrhoeal ill-
Regionally, Africa had the greatest Food safety education for consumers has ness and death, is to improve the safety
burden of diarrhoeal disease from con- been shown to affect behaviour change, of complementary foods introduced to

a
National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australian Capital Territory 0200, Australia.
b
Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, United States of America (USA).
c
Emerging Pathogens Institute, University of Florida, Gainesville, USA.
d
Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
Correspondence to Martyn Kirk (email: [email protected]).
(Submitted: 9 March 2016 – Revised version received: 22 June 2016 – Accepted: 23 June 2016 – Published online: 25 November 2016 )

Bull World Health Organ 2017;95:233–234 | doi: http://dx.doi.org/10.2471/BLT.16.173229 233

infants to supplement breast or formula evidence could start with better knowl- targeted at mothers and children, along
feeding. Contamination of these foods edge of the disease burden: identifying with the development and implementa-
may result in serious enteric infections, the localized burden of foodborne dis- tion of effective surveillance systems to
despite the partial protective effects ease in low- and middle-income settings measure progress in reducing diarrhoeal
of breastfeeding.7,10,11 Food-producing within specific countries; development diseases. An economic analysis of the
animals often live in close proximity to of disease burden estimates for specific costs of foodborne disease and the
humans; additional efforts are required foods that may present high risks; and benefits of interventions would support
to prevent exposure of young children to elucidation of the human disease burden these efforts. Finally, research is needed
the excreta of these animals, which may from chemicals in food. Despite the high to develop vaccines for use in animals
cause zoonotic infections. Efforts to re- burden of diarrhoeal diseases in chil- and humans against agents that are com-
duce the disease burden and improve the dren, there appear to be no intervention monly foodborne, such as norovirus. ■
nutrition of young children may not be studies identifying how much these dis-
effective without concomitant controls eases could be prevented by safer food. Acknowledgements
on exposure to foodborne, waterborne This contrasts with the many studies Arie Havelaar is also affiliated with the
and zoonotic pathogens. assessing the effects of improved water Institute for Risk Assessment Science,
If we are to reduce the high burden and sanitation on diarrhoeal disease.12 Faculty of Veterinary Medicine, Utrecht
of foodborne illness in young children, For better disease control we need to University, Utrecht, the Netherlands.
we need high-level advocacy for re- assemble a credible information base on
search that will identify and validate the effects of food safety interventions Competing interests: None declared.
specific food safety interventions. A to prevent foodborne diarrhoea in chil-
research agenda to address the lack of dren. This would inform interventions

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234 Bull World Health Organ 2017;95:233–234| doi: http://dx.doi.org/10.2471/BLT.16.173229