Health impact, food safety assessment and mitigation –

experience from a case study in the region

Fred Unger & Hung Nguyen-Viet
International Livestock Research Institute

Seminar at Gadjah Mada University, Faculty of Veterinary Medicine

Yogyakarta, 5 August 2019
 Outline

• Some definitions (health; hazard & risk)

• Health impact of food borne diseases
• Risk analysis (assessment, management)
• Case study example - Vietnam
 Health and health impact – some definitions

Health
“ The absence of diseases”
“ A state of complete physical, mental, and social well-being and
not merely the absence of disease or infirmity” WHO

Food borne disease (FBD)

is any illness resulting from the food spoilage of contaminated
food, pathogens (Bacteria, viruses, or parasites) that contaminate
food, as well as chemical, physical or natural toxins/particals.
 Health and health impact – some definitions

Health impact
Information on health impacts are expressed in disease burden

Burden of diseases
• Often quantified in terms of disability-adjusted life years
(DALYs)
– Expressed in health statistics as the number of years lost due to ill-
health, disability and early dead, which quantify the number of years
lost due to disease or one lost year of healthy live
– note that DALYs may not address sufficiently social impact of FBD e.g.
trade impacts or losses in agriculture and food sector
 Hazards and risks – some definitions

Hazard (generic)
An agent, substance or action that has the potential to cause an
undesired event

Risk (generic)
The probability of an undesired event and its consequences
 FBD- a new priority – most from livestock
WHO – GlobalMillions
estimates
DALYsoflost
food borne
per year diseases burden
(global)

• 31 hazards
• Worldwide
• 5 years period, various experts

• Helminthes
• Microbes
• Toxins
• Aflatoxins

Havelaar et al., 2015 ?¿: Most important among these 4?

 FBD- a new priority – most from livestock
WHO
Millions–DALYs lostestimates
Global per year (global)
of FBD burden
31 hazards
• 600 mio illnesses
20,000,000
• 420,000 deaths
18,000,000
• 33 million DALYs
16,000,000

14,000,000 Other toxins

12,000,000 Aflatoxins
10,000,000 Helminths
8,000,000 Microbial
6,000,000

4,000,000

2,000,000

i a a g d
As fric pin
o p e
A o l
el ve
dev De
e r
th
O

Havelaar et al., 2015

 GLOBAL BURDEN OF FBD BURDEN,
REGIONAL DIFFERENCES

Eastern Southeast Western

Africa America Mediterranean Europe Asia Pacific

Havelaar et al., 2018

 FBD burden is a significant (and growing) public
health problem in emerging Asia

Comparative Public Health Burden:

Disability Adjusted Life Years Lost Per 100,000
China Indonesia Laos Malaysia Myanmar Philippines Thailand Vietnam

Tuberculosis 148 1514 1820 146 1716 1063 299 414

(2016)
HIV/AIDS 67 900 337 1080 904 25 1205 440
(2016)
Malaria 1 50 36 1 31 3 3 1
(2016)

Food-borne 272 693 933 293 711 293 685 390

disease
(2010)

WHO Statistics

Jaffee, 2018, World Bank

 FERG key results

• Demonstrated that almost 1 in 10 people fall ill every

year from eating contaminated food
• Children less than 5 years of age are at highest risk
• Cosiderable regional difference on specific FBD burden
• FBD are of a similar burden in order of magnitude as
the “big three” infectious diseases (HIV, TB, Malaria)
 FERG limitations

This estimates are expected to be conservative

which may result in underestimates rather than
overestimates
– E.g. In USA alone each year, 1 in 6 Americans get sick
from eating contaminated food (CDC, 2016)
– Vietnam, 1 reported FBD versus 100 estimated
unreported
– Underestimates for Europe for Salmonella
• Germany, approx. factor 7 for Salmonella
• Poland, approx. factor 62
 MORE INFORMATION

• WHO website
http://www.who.int/foodsafety/areas_work/foodborne-dis
eases/ferg/en/

• PLOS collection
http://collections.plos.org/ferg2015

• Interactive tools
https://extranet.who.int/sree/Reports?op=vs&path=/WHO_HQ
_Reports/G36/PROD/EXT/FoodborneDiseaseBurden
• Source: IHME, 2016. http://vizhub.healthdata.org/gbd-compare/
Risk Analysis

• Science-based approach to risk management

• Estimate, evaluate and discuss risk of adverse
events (e.g. FBD) and their management
qualitative and/or quantitative approach
• Driven by political consideration and managers
• Limited time scale & resources
 Hazards # Risk

Hazard
• Something that can cause adverse effects (harm)
Risk
• Likelihood of occurrence of unwanted outcome AND
magnitude of consequences given its occurrence
• probability plus consequences
Standard setting organisations

SPS Agreement: Agreement on Sanitary and

Phytosanitary Measures
Risk Analysis – CODEX framework

Risk Risk
Assessment Management

*Science based *Policy based

Risk
Communication
*Interactive exchange of
information and opinions
concerning risks
Risk assessment

Codex Alimentarius Commission framework for food safety risk assessment, adapted by Grace et
al.
 Hazard
Hazard
identification
identification
Risk characterization
Hazard
Hazard Exposure
Exposure
characterization assessment
characterization assessment
• An estimate of the likelihood and
Risk
Risk severity of the “negative”effect which
characterization
characterization
could occur in a given population
– Estimate likelyhood of FBD in humans due
to Salmonella
• Degree of confidence in estimates:
– some uncertainty and variability occurs
 Hazard
Hazard
identification
identification
Risk characterization
Hazard
Hazard Exposure
Exposure
characterization assessment
characterization assessment
• Uncertainty: Lack of knowledge
Risk
Risk
– Associated with the data themselves
characterization
characterization • Data uncertainty might arise in the evaluation and
extrapolation of information obtained from
epidemiological, microbiological and laboratory
animal studies
• Variability: Variation in a system
– Biological variation: difference in virulence of
hazard
• e.g. Bird Flu, African Swine Fever
– Variability in susceptibility within the human
population:
• Malaria in humans
 Risk characterization
(qualitative risk assessment)

PROBABILITY/CONSEQUENCE MATRIX
High Negligible Very low Low Moderate High Extreme
PROBABILITY

Moderate Negligible Very low Low Moderate High Extreme

Slight Negligible Very low Low Moderate High Extreme

Low Negligible Negligible Very low Low Moderate High

Very low Negligible Negligible Negligible Very low Low Moderate

Extremely low Negligible Negligible Negligible Negligible Very low Low

Negligible Negligible Negligible Negligible Negligible Negligible Very low

Negligible Very low Low Moderate High Extreme

CONSEQUENCE
 Risk Management

Process of deciding and implementing mitigation

methods for the appropriate level of safety.
NOTE there is usually no “0” risk.

Food security

Food safety
 Risk Management

• What can be done to eliminate or reduce hazard?

• How effective and feasible are options?
• What is cost-effectiveness of control options?
• What is the expected compliance of actors?
• What impacts do options have
• e.g. enforced closing of life bird markets during bird flu
What is best option?
Safer Pork for Vietnamese consumers

A case study
 Background - pork in Vietnam

Pork is an important component of the Vietnamese diet

• The most widely consumed meat: 29.1Kg/person
• 83% comes from very small or small farms
• 76% of pigs are processed in small slaughtering
• Preference for fresh “warm” pork supplied in traditional
markets (>80% of all pork marketed)
Food safety among the most pressing issues for people in Vietnam, more
important than education or health care
• Food exports relatively well managed but deficits
in domestic markets
 Pork safety assessments and pathways towards safer pork
PigRISK (2012-2017) SAFE pork (ongoing)

• Interdisciplinary team
• Risk based approach
• Food safety hazards:
– Biological and chemical

Research questions
Is pork safe in Vietnam? Research questions
Methods: What are faesable options for safer Pork?
Quantitative and qualitative risk assessment Methods:
Assess cost of FBD illness (hospitalisation) Food safety (FS) performance of value chain
Cross-contamination Salmonella (household) FS interventions (e.g. RCT)
Risk communication
Farm to fork approach
 Methodology
Risk analysis framework

Hazard identification
• Lit review, expert opionon
Hazard characterisation
• Dose-response, from literature (clinical studies)
Exposure assessment
• Prevalence studies, dose-response,
pork intake, gender/age aspects Risk management
Risk characterisation
• Magnitude of the risk
 Hazard identification

Pork/Food-borne disease
Parasitic
 Cysticercus cellulosae
 Trichinella spiralis
 Toxoplasma gondii Tape worms
 Fasciola spp.
Bacterial
 Bacillus cereus
 Brucella suis
 Campylobacter spp. Salmonella spp.
 Salmonella spp.
 Staphylococcus aurues
 Streptococcus suis
 Shiga toxin producing E. coli
 Yersinia enterocolitica
Virus
 Hepatitis E
 Norovirus

Source: PigRISK
 Results from risk assessment

Chemical risk assessment: Risk due to chemical hazards is low (heavy

metals, grow promoters and antibiotics) low – overwhelming majority of
meat samples negative tested
Microbial Risk assessment:
Salmonella contamination started at farm and increased along the pork
chain (farm – slaughter – market) mainly related to poor hygienic practices
44.7% to 83% of pork across different retail contaminated with
Salmonella
Risk for pork consumer: 1 – 2 person from 10 (17%) estimated to suffer
Salmonella caused FBD annually
Miss-perception towards risk – public most concerned on chemical
hazards but major health risk related to microbiological hazards
 Investments in FSimpact
Potential health can save
– FBDlives and $$$
Vietnam

Hospitalization costs of foodborne diarrhoea per treatment episode and

per day: USD 107 and USD 34 respectively

• 94 million people
• Cases of foodborne diseases (FBD) by
Salmonella in pork at 17%: 16 million get
sick annually
• 40% get hospitalised: 6.4 million
• Cost $ 107 to treat a case (episode):
$ 684 million (0.4% GDP)
• Potential intervention to reduce 20% FBD
burden: $ 134 million SAVED
 Other results

• Poor food safety (FS) outcomes across all retail types

Street food Canteens „Organic“ food Supermarket/ Native pigs,

Traditional/
wet market (80%) chains, niche but convienient stores niche market, „safe
by nature
emerging

• Related to risk communication

 Trust in media was lowest with social media and highest
with T.V./local radio respectively.
 Most VC actors relate “Safe Pork” to not using
antibiotics/growth promoters and less to poor hygiene.
From Assessment to interventions

Pig RISK quantified the risk for the consumer due

microbial and chemical hazards
Is pork in Vietnam safe? - It is not !

Limited progress has been made on how to actually

reduce the risk for the consumer

SAFE Pork
Focus on food safety interventions along
pork value chains
Goal: To improve pork safety, by developing,
testing and promoting incentive-based
interventions that are sustainable & scalable
 SAFE Pork – interventions
Challenges for improving food safety including pork

• Various approaches to improving safety had been tried, largely based

on systems used in developed countries e.g.:
– GAP, traceability, certification, modernising retail etc
• However, safe meat production has not yet take a significant share of
the market in Vietnam (e.g. VietGAHP < 5%)
• The key constraints to uptake include:
– high cost of adoption, lack of benefits from changing behaviour
• To overcome these constraints our focus will be on:
– gradual improvements to the food system in place, rather than
introduction of a new system
– incentive-based, light-touch interventions
 Pilot intervention
Use of tailored slaughter grid

The improvement in hygiene (using grid versus

floor) was indicated by lower coliform load (p
= 0.002) on the carcass surface compared to
the control.

The pilot trial also demonstrated that technical

solutions must go along with behaviour
change of butchers and require incentive
 Safe PORK - low-cost innovations

Simple, rapid, cheap tests that detect contaminated food

– Could be used directly by retailers or consumer to have direct verification of
safety e.g. food sniffer

Reduce contamination of pork

– Portable ozone machines to plug into water supply
• 2 slaughterhouses identified, Hanoi and Hung Yen
– Avoid floor slaughter
– Training, antimicrobial cutting board, clothes etc.. (retailer)
(tested under lab condition)
 Safe PORK - low-cost innovations

• Reduce use of antimicrobial (in collaboration with private sector)

– Replacement of antimicrobials by pro-biotics

• Increasing transparency and traceability in food system

– 24 hour on farm, branding and certification,
done with private sector
 Safe PORK - innovations

• Assessment of the potential to use nudges for improved

food safety in the pork value chain in Vietnam

• Risk communication
 Media, risk assessors, value chain actors – training &
materials
 FBD- a new Safe
priority – most from livestock
PORK
Millions DALYs lost per year (global)
Conclusions & next steps
From assessments:
• Pork is not safe & the risk is considerable
• Modern retail not safer than traditional retail
• Microbiological hazards are most important
Pathways towards safer pork:
• Techincal innovations require also practice change
• Government efforts to improve FS need to include all retail types -
the informal sector has been relatively ignored.
• Risk communication messages must be tailored to the audience and
use most trusted channels
Next steps (2019-2021):
 Overall conclusions

• FBD are a major health concern comparable to

‚big three‘ infectious diseases
• Risk analysis – important tool to evaluate risk
and make evidence based decisions to mitigate
risks in a context with limited resources
 Focus on the few relevant and not many trivial
• Case study example
• Safer food can be achieved but technical
solutions need to be:
• Evidence
• Feasible
• Incentivized
• Cost - beneficial
 Group work

Please discuss the food safety situation

in Jogjakarta and propose:
• 3 top concerns and identify
• 3 top hazards in food safety
 better lives through livestock

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