Food safety and foodborne illness

Fact sheet N°237

Reviewed March 2007

Food safety is an increasingly important public health issue. Governments all over the world are
intensifying their efforts to improve food safety. These efforts are in response to an increasing
number of food safety problems and rising consumer concerns.

Definition of foodborne illness: Foodborne illnesses are defined as diseases, usually either
infectious or toxic in nature, caused by agents that enter the body through the ingestion of food.
Every person is at risk of foodborne illness.

Magnitude of foodborne illness: Foodborne diseases are a widespread and growing public
health problem, both in developed and developing countries.

 The global incidence of foodborne disease is difficult to estimate, but it has been reported
that in 2005 alone 1.8 million people died from diarrhoeal diseases. A great proportion of
these cases can be attributed to contamination of food and drinking water. Additionally,
diarrhoea is a major cause of malnutrition in infants and young children.
 In industrialized countries, the percentage of the population suffering from foodborne
diseases each year has been reported to be up to 30%. In the United States of America
(USA), for example, around 76 million cases of foodborne diseases, resulting in 325,000
hospitalizations and 5,000 deaths, are estimated to occur each year.
 While less well documented, developing countries bear the brunt of the problem due to
the presence of a wide range of foodborne diseases, including those caused by parasites.
The high prevalence of diarrhoeal diseases in many developing countries suggests major
underlying food safety problems.
 While most foodborne diseases are sporadic and often not reported, foodborne disease
outbreaks may take on massive proportions. For example, in 1994, an outbreak of
salmonellosis due to contaminated ice cream occurred in the USA, affecting an estimated
224,000 persons. In 1988, an outbreak of hepatitis A, resulting from the consumption of
contaminated clams, affected some 300,000 individuals in China.

Major foodborne diseases from microorganisms

 Salmonellosis is a major problem in most countries. Salmonellosis is caused by the

Salmonella bacteria and symptoms are fever, headache, nausea, vomiting, abdominal pain
and diarrhoea. Examples of foods involved in outbreaks of salmonellosis are eggs,
poultry and other meats, raw milk and chocolate.
 Campylobacteriosis is a widespread infection. It is caused by certain species of
Campylobacter bacteria and in some countries, the reported number of cases surpasses
the incidence of salmonellosis. Foodborne cases are mainly caused by foods such as raw
milk, raw or undercooked poultry and drinking water. Acute health effects of
campylobacteriosis include severe abdominal pain, fever, nausea and diarrhoea. In two to
 ten per cent of cases the infection may lead to chronic health problems, including reactive
arthritis and neurological disorders.
 Infections due to enterohaemorrhagic (causing intestinal bleeding) E. coli, e.g. E.coli
O157, and listeriosis are important foodborne diseases which have emerged over the last
decades. Although their incidence is relatively low, their severe and sometimes fatal
health consequences, particularly among infants, children and the elderly, make them
among the most serious foodborne infections.
 Cholera is a major public health problem in developing countries, also causing enormous
economic losses. The disease is caused by the bacterium Vibrio cholerae. In addition to
water, contaminated foods can be the vehicle of infection. Different foods, including rice,
vegetables, millet gruel and various types of seafood have been implicated in outbreaks
of cholera. Symptoms, including abdominal pain, vomiting and profuse watery diarrhoea,
may lead to severe dehydration and possibly death, unless fluid and salt are replaced.

Other food safety problems: some major examples

 Naturally occurring toxins, such as mycotoxins, marine biotoxins, cyanogenic

glycosides and toxins occurring in poisonous mushrooms, periodically cause severe
intoxications. Mycotoxins, such as aflatoxin and ochratoxin A, are found at measurable
levels in many staple foods; the health implications of long-term exposure of such toxins
are poorly understood.
 Unconventional agents such as the agent causing bovine spongiform encephalopathy
(BSE, or "mad cow disease"), is associated with variant Creutzfeldt-Jakob (vCJD)
Disease in humans. Consumption of bovine products containing brain tissue is the most
likely route for transmission of the agent to humans.
 Persistant Organic Pollutants (POPs) are compounds that accumulate in the
environment and the human body. Known examples are Dioxins and PCBs
(polychlorinated biphenyls). Dioxins are unwanted byproducts of some industrial
processes and waste incineration. Exposure to POPs may result in a wide variety of
adverse effects in humans.
 Metals: such as lead and mercury, cause neurological damage in infants and children.
Exposure to cadmium can also cause kidney damage, usually seen in the elderly. These
(and POPs) may contaminate food through pollution of air, water and soil.

Costs of foodborne diseases

 Food contamination creates an enormous social and economic burden on communities

and their health systems. In the USA, diseases caused by the major pathogens alone are
estimated to cost up to US $35 billion annually (1997) in medical costs and lost
productivity. The re-emergence of cholera in Peru in 1991 resulted in the loss of US $500
million in fish and fishery product exports that year.

Challenges and developments in food safety

The safety of food derived from biotechnology needs to be carefully assessed. To provide the
scientific basis for decisions regarding human health, new methods and policies to assess such
food need to be developed and agreed upon internationally. The assessment should consider
health benefits as well as possible negative health implications. Crops modified to resist pests,
foods with allergens removed or food with an increase of essential nutrients are possible
examples of the former, while anti-microbial markers in some genetically modified foods have
been suggested to be an example of the latter. The weighing of potential risks and benefits is an
important aspect of assessment of foods derived from biotechnology that has not received much
attention in the past. Likewise, clear communication of the basis for safety assessment in this
area is generally lacking at national and international levels.

If not properly monitored and assessed, changes in animal husbandry practices, including
feeding, may have serious implications for food safety. For example, increased use of ruminant
bone and meat meal as feed supplement for cattle appear to have played a role in the emergence
of BSE.

Adding low levels of antibiotics to animal feed in order to increase growth rate has raised
concern about the transfer of antibiotic resistance to human pathogens from this practice.

Modern intensive agricultural practices contribute to increasing the availability of affordable

foodstuffs and the use of food additives can improve the quality, quantity and safety of the food
supply. However, appropriate controls are necessary to ensure their proper and safe use along the
entire food chain. Pre-market review and approval followed by continuous monitoring are
necessary to ensure the safe use of pesticides, veterinary drugs and food additives.

Other challenges, which need to be addressed to help ensure food safety, include the
globalization of trade in food, urbanization, changes in lifestyles, international travel,
environmental pollution, deliberate contamination and natural and manmade disasters. The food
production chain has become more complex, providing greater opportunities for contamination
and growth of pathogens. Many outbreaks of foodborne diseases that were once contained within
a small community may now take on global dimensions.

Future directions for food safety at the World Health Organization (WHO)

In partnership with other stakeholders, WHO is developing policies that will further promote the
safety of food. These policies cover the entire food chain from production to consumption and
will make use of different types of expertise.

The Work of the WHO Department of Food Safety and other WHO programmes and
departments includes strengthening food safety systems, promoting good manufacturing
practices and educating retailers and consumers about appropriate food handling. Education of
consumers and training of food handlers in safe food handling is one of the most critical
interventions in the prevention of foodborne illnesses.

 WHO is promoting in-country laboratory-based surveillance of priority foodborne

diseases in humans and animals, as well as the monitoring of pathogens in food. In co-
operation with its Member States, WHO is working to support the development of
internationally agreed-upon guidelines for data collection in countries. WHO is also
 compiling outbreak and surveillance databases, and is broadening its epidemic
surveillance capacity to include foodborne disease outbreaks.
 WHO is expanding its global network of participating institutions to monitor chemical
contamination of the food supply, particularly in developing countries.
 WHO is promoting the use of all food technologies which may contribute to public
health, such as pasteurization, food irradiation and fermentation.
 WHO has undertaken an important new initiative to strengthen the scientific basis of food
safety activities through the establishment of a WHO/FAO (Food and Agriculture
Organization of the United Nations) expert advisory body to assess microbiological risks
in food.
 WHO is increasing its involvement in the work of the FAO/WHO Codex Alimentarius
Commission, whose standards, guidelines and recommendations are regarded as the
international reference for food safety requirements by the World Trade Organization.
WHO and FAO is initiating a thorough review of Codex primo 2002.
 Biotechnology has become a major public issue in developed as well as developing
countries. WHO, jointly with FAO, will convene a series of expert consultations to assess
the safety and nutritional aspects of foods derived from genetically modified plants,
microorganisms, and animals. WHO has initiated work to establish a knowledge base
focusing on a broader evaluation of risks, benefits and other considerations related to the
production and consumption of foods derived from biotechnology.
Foodborne diseases, emerging
Fact sheet N°124
Revised January 2002

Some foodborne diseases are well recognized, but are considered emerging because they have
recently become more common. For example, outbreaks of salmonellosis have been reported for
decades, but within the past 25 years the disease has increased in incidence on many continents.
In the Western hemisphere and in Europe, Salmonella serotype Enteritidis (SE) has become the
predominant strain. Investigations of SE outbreaks indicate that its emergence is largely related
to consumption of poultry or eggs.

While cholera has devastated much of Asia and Africa for years, its introduction for the first time
in almost a century on the South American continent in 1991 makes it another example of an
infectious disease that is both well-recognized and emerging. While cholera is often waterborne,
many foods also transmit infection. In Latin America, ice and raw or underprocessed seafood are
important epidemiological pathways for cholera transmission.

Other foodborne pathogens are considered emerging because they are new microorganisms or
because the role of food in their transmission has been recognized only recently. Infection with
Escherichia coli serotype O157:H7 (E. coli) was first described in 1982. Subsequently, it has
emerged rapidly as a major cause of bloody diarrhoea and acute renal failure. The infection is
sometimes fatal, particularly in children. Outbreaks of infection, generally associated with beef,
have been reported in Australia, Canada, Japan, United States, in various European countries,
and in southern Africa. Outbreaks have also implicated alfalfa sprouts, unpasteurized fruit juice,
lettuce, game meat and cheese curd.

In 1996, an outbreak of Escherichia coli O157:H7 in Japan affected over 6,300 school children
and resulted in 2 deaths. This is the largest outbreak ever recorded for this pathogen.

Listeria monocytogenes (Lm) is considered emerging because the role of food in its transmission
has only recently been recognized. In pregnant women, infections with Lm can cause abortion
and stillbirth, and in infants and persons with a weakened immune system it may lead to
septicemia (blood poisoning) and meningitis. The disease is most often associated with
consumption of foods such as soft cheese and processed meat products that are kept refrigerated
for a long time because Lm can grow at low temperatures. Outbreaks of listeriosis have been
reported from many countries, including Australia, Switzerland, France and the United States.
Two recent outbreaks of Listeria monocytogenes in France in 2000 and in the USA in 1999 were
caused by contaminated pork tongue and hot dogs respectively.

Foodborne trematodes are also emerging as a serious public health problem, especially in south-
east Asia but also in Latin America, in part due to a combination of increased aquaculture
production, often under unsanitary conditions, and of consumption of raw and lightly processed
fresh water fish and fishery products. Foodborne trematodes can cause acute liver disease, and
may lead to liver cancer. An estimated 40 million people world wide are affected.
Bovine Spongiform Encephalopathy (BSE), a fatal, transmissible, neurodegenerative disease of
cattle, was first discovered in the United Kingdom in 1985. The cause of the disease was traced
to an agent related to scrapie in sheep, which contaminated recycled bovine carcasses used to
make meat and bone meal additives for cattle feed. Recycling of the BSE agent led to a
distributed common source epidemic of more than 180,000 diseased animals in the UK alone.
The agent affects the brain and spinal cord of cattle and lesions are characterized by sponge-like
changes visible in a microscope. At this time, 19 countries have reported endemic BSE cases and
the disease is no longer confined to the European Community: a case of BSE has been reported
in the cattle herd of Japan.

In human populations, exposure to the BSE agent (probably in contaminated bovine-based food
products) has been strongly linked to the appearance in 1996 of a new transmissible spongiform
encephalopathy of humans called variant Creutzfeldt-Jakob Disease (vCJD). As of January 2002,
119 people have developed vCJD, most are from the UK but five cases have been reported from
France.

Why do foodborne diseases emerge?

New foodborne disease threats occur for a number of reasons. These include increase in
international travel and trade, microbial adaptation and changes in the food production system, as
well as human demographics and behaviour:

 The globalization of the food supply: A large outbreak of cyclosporiasis occurred in

North America in 1996-7 linked to contaminated raspberries imported from South
America.

 The inadvertant introduction of pathogens into new geographic areas: Vibrio

cholerae was introduced into waters off the coast of southern United States when a cargo
ship discharged contaminated ballast water in 1991. It is likely that a similar mechanism
led to the introduction of cholera for the first time this century into South America in
1991.

 Travellers, refugees, and immigrants exposed to unfamiliar foodborne hazards

while abroad: International travellers may become infected by foodborne pathogens that
are uncommon in their countries. It is estimated that about 90% of all cases of
salmonellosis in Sweden are imported.

 Changes in microorganisms: Changes in microbial populations can lead to the evolution

of new pathogens, development of new virulent strains in old pathogens, development of
antibiotic resistance that might make a disease more difficult to treat, or to changes in the
ability to survive in adverse environmental conditions.

 Change in the human population: The population of highly susceptible persons is

expanding world-wide because of ageing, malnutrition, HIV infections and other
underlying medical conditions. Age is an important factor in susceptibility to foodborne
infections because those at the extremes of age have either not developed or have
 partially lost protection from infection. Particularly for the elderly, foodborne infections
are likely to invade their blood stream and lead to severe illness with high mortality rates.
People with a weakened immune system also become infected with foodborne pathogens
at lower doses which may not produce an adverse reaction in healthier persons. Seriously
ill persons, suffering, for example, from cancer or AIDS, are more likely to succumb to
infections with Salmonella, Campylobacter, Listeria, Toxoplasma, Cryptosporidium, and
other foodborne pathogens. In developing countries reduced immunity due to poor
nutritional status render people, particularly infants and children, more susceptible to
foodborne infections.

 Changes in lifestyle: Greater numbers of people go out and eat meals prepared in
restaurants, canteens, fast food outlets, and by street food vendors. In many countries, the
boom in food service establishments is not matched by effective food safety education
and control. Unhygienic preparation of food provides ample opportunities for
contamination, growth, or survival of foodborne pathogens.

Food-borne diseases pose a considerable threat to human health and the economy of individuals,
families and nations. Their control requires a concerted effort on the part of the three principal
partners, namely governments, the food industry and consumers. As part of its food safety
education campaign, WHO issued the 5 Keys to Safer Food and a guide on Safe Food for
Travellers.