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Illness and death from diseases caused by contaminated food are a constant threat to public health and a significant impediment to socio-economic development worldwide. To measure the global and regional burden of foodborne disease (FBD), the World Health Organization (WHO) established the Foodborne Disease Burden Epidemiology Reference Group (FERG), which here reports their first estimates of the incidence, mortality, and disease burden due to 31 foodborne hazards. We find that the global burden of FBD is comparable to those of the major infectious diseases, HIV/AIDS, malaria and tuberculosis. The most frequent causes of foodborne illness were diarrheal disease agents, particularly norovirus and Campylobacter spp. Diarrheal disease agents, especially non-typhoidal Salmonella enterica, were also responsible for the majority of deaths due to FBD. Other major causes of FBD deaths were Salmonella Typhi, Taenia solium and hepatitis A virus. The global burden of FBD caused by the 31 hazards in 2010 was 33 million Disability Adjusted Life Years (DALYs); children under five years old bore 40% of this burden. The 14 subregions, defined on the basis of child and adult mortality, had considerably different burdens of FBD, with the greatest falling on the subregions in Africa, followed by the subregions in South-East Asia and the Eastern Mediterranean D subregion. Some hazards, such as non-typhoidal S. enterica, were important causes of FBD in all regions of the world, whereas others, such as certain parasitic helminths, were highly localised. Thus, the burden of FBD is borne particularly by children under five years old-although they represent only 9% of the global population-and people living in low-income regions of the world. These estimates are conservative, i.e., underestimates rather than overestimates; further studies are needed to address the data gaps and limitations of the study. Nevertheless, all stakeholders can contribute to improvements in food safety throughout the food chain by incorporating these estimates into policy development at national and international levels. [ABSTRACT FROM AUTHOR]

Background: Foodborne diseases are important worldwide, resulting in considerable morbidity and mortality. To our knowledge, we present the first global and regional estimates of the disease burden of the most important foodborne bacterial, protozoal, and viral diseases.Methods and Findings: We synthesized data on the number of foodborne illnesses, sequelae, deaths, and Disability Adjusted Life Years (DALYs), for all diseases with sufficient data to support global and regional estimates, by age and region. The data sources included varied by pathogen and included systematic reviews, cohort studies, surveillance studies and other burden of disease assessments. We sought relevant data circa 2010, and included sources from 1990-2012. The number of studies per pathogen ranged from as few as 5 studies for bacterial intoxications through to 494 studies for diarrheal pathogens. To estimate mortality for Mycobacterium bovis infections and morbidity and mortality for invasive non-typhoidal Salmonella enterica infections, we excluded cases attributed to HIV infection. We excluded stillbirths in our estimates. We estimate that the 22 diseases included in our study resulted in two billion (95% uncertainty interval [UI] 1.5-2.9 billion) cases, over one million (95% UI 0.89-1.4 million) deaths, and 78.7 million (95% UI 65.0-97.7 million) DALYs in 2010. To estimate the burden due to contaminated food, we then applied proportions of infections that were estimated to be foodborne from a global expert elicitation. Waterborne transmission of disease was not included. We estimate that 29% (95% UI 23-36%) of cases caused by diseases in our study, or 582 million (95% UI 401-922 million), were transmitted by contaminated food, resulting in 25.2 million (95% UI 17.5-37.0 million) DALYs. Norovirus was the leading cause of foodborne illness causing 125 million (95% UI 70-251 million) cases, while Campylobacter spp. caused 96 million (95% UI 52-177 million) foodborne illnesses. Of all foodborne diseases, diarrheal and invasive infections due to non-typhoidal S. enterica infections resulted in the highest burden, causing 4.07 million (95% UI 2.49-6.27 million) DALYs. Regionally, DALYs per 100,000 population were highest in the African region followed by the South East Asian region. Considerable burden of foodborne disease is borne by children less than five years of age. Major limitations of our study include data gaps, particularly in middle- and high-mortality countries, and uncertainty around the proportion of diseases that were foodborne.Conclusions: Foodborne diseases result in a large disease burden, particularly in children. Although it is known that diarrheal diseases are a major burden in children, we have demonstrated for the first time the importance of contaminated food as a cause. There is a need to focus food safety interventions on preventing foodborne diseases, particularly in low- and middle-income settings. [ABSTRACT FROM AUTHOR]

Background: Lyme borreliosis (LB) is the most commonly reported tick-borne infection in Europe and North America. In the last 15 years a 3-fold increase was observed in general practitioner consultations for LB in the Netherlands. To support prioritization of prevention and control efforts for LB, we estimated its burden expressed in Disability-Adjusted Life Years (DALYs). Methods: We used available incidence estimates for three LB outcomes: (i) erythema migrans (EM), (ii) disseminated LB and (iii) Lyme-related persisting symptoms. To generate DALYs, disability weights and duration per outcome were derived using a patient questionnaire including health-related quality of life as measured by the EQ-5D. Results: We estimated the total LB burden for the Netherlands in 2010 at 10.55 DALYs per 100000 population (95% CI: 8.80-12.43); i.e. 0.60 DALYs for EM, 0.86 DALYs for disseminated LB and 9.09 DALYs for Lyme-related persisting symptoms. Per patient this was 0.005 DALYs for EM, 0.113 for disseminated LB and 1.661 DALYs for a patient with Lyme-related persisting symptoms. In a sensitivity analysis the total LB burden ranged from 7.58 to 16.93 DALYs per 100000 population. Conclusions: LB causes a substantial disease burden in the Netherlands. The vast majority of this burden is caused by patients with Lyme-related persisting symptoms. EM and disseminated Lyme have a more modest impact. Further research should focus on the mechanisms that trigger development of these persisting symptoms that patients and their physicians attribute to LB. [ABSTRACT FROM AUTHOR]

Toxoplasma gondii intervention strategies should protect the general population, including pregnant women. Freezing of meat destined for undercooked consumption is the most readily applicable option, but in the long term, more health benefits can be expected from cat vaccination.Infection with Toxoplasma gondii is acquired through consumption of undercooked infected meat, or by uptake of cat-shed oocysts. Although congenital toxoplasmosis is generally considered to contribute most to the disease burden of T. gondii, ocular disease from acquired infection was recently shown to add substantially to the burden. In addition, toxoplasmosis in immune-compromised individuals usually results from reactivation of an infection acquired earlier in life. Nevertheless, prevention of toxoplasmosis commonly targets mainly pregnant women. We summarize current prevention strategies of congenital toxoplasmosis and evaluate options to improve protection of the general population (including pregnant women). To protect the general population, freezing of meat destined for raw or undercooked consumption is the most readily applicable option, especially when limited to meat from animals originating from nonbiosecure husbandry systems. In the long term, more health benefits are expected from cat vaccination; therefore, development of a cat vaccine and evaluation of its implementation is a research priority. [ABSTRACT FROM PUBLISHER]

Background: In 2015, new disability weights (DWs) for infectious diseases were constructed based on data from four European countries. In this paper, we evaluated if country, age, sex, disease experience status, income and educational levels have an impact on these DWs. Methods: We analyzed paired comparison responses of the European DW study by participants’ characteristics with separate probit regression models. To evaluate the effect of participants’ characteristics, we performed correlation analyses between countries and within country by respondent characteristics and constructed seven probit regression models, including a null model and six models containing participants’ characteristics. We compared these seven models using Akaike Information Criterion (AIC). Results: According to AIC, the probit model including country as covariate was the best model. We found a lower correlation of the probit coefficients between countries and income levels (range rs: 0.97–0.99, P < 0.01) than between age groups (range rs: 0.98–0.99, P < 0.01), educational level (range rs: 0.98–0.99, P < 0.01), sex (rs = 0.99, P < 0.01) and disease status (rs = 0.99, P < 0.01). Within country the lowest correlations of the probit coefficients were between low and high income level (range rs = 0.89–0.94, P < 0.01). Conclusions: We observed variations in health valuation across countries and within country between income levels. These observations should be further explored in a systematic way, also in non-European countries. We recommend future researches studying the effect of other characteristics of respondents on health assessment., Version of Record

Campylobacteriosis in humans is one of the most frequently reported bacterial zoonoses. Poultry are the source of a high proportion of cases. Interventions to control Campylobacter in poultry have not been implemented effectively due to economic constraints and consumer acceptance.Campylobacteriosis in humans, caused by Campylobacter jejuni and Campylobacter coli, is the most common recognized bacterial zoonosis in the European Union and the United States. The acute phase is characterized by gastrointestinal symptoms. The long-term sequelae (Guillain-Barré syndrome, reactive arthritis, and postinfectious irritable bowel syndrome) contribute considerably to the disease burden. Attribution studies identified poultry as the reservoir responsible for up to 80% of the human Campylobacter infections. In the European Union, an estimated 30% of the human infections are associated with consumption and preparation of poultry meat. Until now, interventions in the poultry meat production chain have not been effectively introduced except for targeted interventions in Iceland and New Zealand. Intervention measures (eg, biosecurity) have limited effect or are hampered by economic aspects or consumer acceptance. In the future, a multilevel approach should be followed, aiming at reducing the level of contamination of consumer products rather than complete absence of Campylobacter. [ABSTRACT FROM AUTHOR]

In 2009, the European Centre for Disease Prevention and Control initiated the ‘Burden of Communicable Diseases in Europe (BCoDE)’ project to generate evidence-based and comparable burden-of-disease estimates of infectious diseases in Europe. The burden-of-disease metric used was the Disability-Adjusted Life Year (DALY), composed of years of life lost due to premature death (YLL) and due to disability (YLD). To better represent infectious diseases, a pathogen-based approach was used linking incident cases to sequelae through outcome trees. Health outcomes were included if an evidence-based causal relationship between infection and outcome was established. Life expectancy and disability weights were taken from the Global Burden of Disease Study and alternative studies. Disease progression parameters were based on literature. Country-specific incidence was based on surveillance data corrected for underestimation. Non-typhoidal Salmonella spp. and Campylobacter spp. were used for illustration. Using the incidence- and pathogen-based DALY approach the total burden for Salmonella spp. and Campylobacter spp. was estimated at 730 DALYs and at 1,780 DALYs per year in the Netherlands (average of 2005–2007). Sequelae accounted for 56% and 82% of the total burden of Salmonella spp. and Campylobacter spp., respectively. The incidence- and pathogen-based DALY methodology allows in the case of infectious diseases a more comprehensive calculation of the disease burden as subsequent sequelae are fully taken into account. Not considering subsequent sequelae would strongly underestimate the burden of infectious diseases. Estimates can be used to support prioritisation and comparison of infectious diseases and other health conditions, both within a country and between countries. [ABSTRACT FROM AUTHOR]

The transfer ratio of bacteria from one surface to another is often estimated from laboratory experiments and quantified by dividing the expected number of bacteria on the recipient surface by the expected number of bacteria on the donor surface. Yet, the expected number of bacteria on each surface is uncertain due to the limited number of colonies that are counted and/or samples that can be analyzed. The expected transfer ratio is, therefore, also uncertain and its estimate may exceed 1 if real transfer is close to 100%. In addition, the transferred fractions vary over experiments but it is unclear, using this approach, how to combine uncertainty and variability into one estimate for the transfer ratio. A Bayesian network model was proposed that allows the combination of uncertainty within one experiment and variability over multiple experiments and prevents inappropriate values for the transfer ratio. Model functionality was shown using data from a laboratory experiment in which the transfer of Salmonella was determined from contaminated pork meat to a butcher's knife, and vice versa. Recovery efficiency of bacteria from both surfaces was also determined and accounted for in the analysis. Transfer ratio probability distributions showed a large variability, with a mean value of 0.19 for the transfer of Salmonella from pork meat to the knife and 0.58 for the transfer of Salmonella from the knife to pork meat. The proposed Bayesian model can be used for analyzing data from similar study designs in which uncertainty should be combined with variability. [ABSTRACT FROM AUTHOR]

Background: Campylobacteriosis contributes strongly to the disease burden of food-borne pathogens. Case-control studies are limited in attributing human infections to the different reservoirs because they can only trace back to the points of exposure, which may not point to the original reservoirs because of cross-contamination. Human Campylobacter infections can be attributed to specific reservoirs by estimating the extent of subtype sharing between strains from humans and reservoirs using multilocus sequence typing (MLST). Methodology/Principal Findings: We investigated risk factors for human campylobacteriosis caused by Campylobacter strains attributed to different reservoirs. Sequence types (STs) were determined for 696 C. jejuni and 41 C. coli strains from endemic human cases included in a case-control study. The asymmetric island model, a population genetics approach for modeling Campylobacter evolution and transmission, attributed these cases to four putative animal reservoirs (chicken, cattle, sheep, pig) and to the environment (water, sand, wild birds) considered as a proxy for other unidentified reservoirs. Most cases were attributed to chicken (66%) and cattle (21%), identified as the main reservoirs in The Netherlands. Consuming chicken was a risk factor for campylobacteriosis caused by chicken-associated STs, whereas consuming beef and pork were protective. Risk factors for campylobacteriosis caused by ruminant-associated STs were contact with animals, barbecuing in non- urban areas, consumption of tripe, and never/seldom chicken consumption. Consuming game and swimming in a domestic swimming pool during springtime were risk factors for campylobacteriosis caused by environment-associated STs. Infections with chicken- and ruminant-associated STs were only partially explained by food-borne transmission; direct contact and environmental pathways were also important. Conclusion/Significance: This is the first case-control study in which risk factors for campylobacteriosis are investigated in relation to the attributed reservoirs based on MLST profiles. Combining epidemiological and source attribution data improved campylobacteriosis risk factor identification and characterization, generated hypotheses, and showed that genotype-based source attribution is epidemiologically sensible. [ABSTRACT FROM AUTHOR]

Employees in different types of work may be intentionally or accidentally exposed to biological agents. Improved risk assessment is needed to identify opportunities to prevent work-related infectious disease. The objective of the current study was to perform a systematic literature review of work-related infectious disease to assist in the identification of occupational infectious disease risks. A literature search of papers on work-related infectious disease published between 1999 and 2008 yielded 1239 papers of which 242 met the selection criteria and were included in the review. The results of the systematic literature review were arranged in a matrix of occupational groups and exposure pathways. Increased risk from infectious diseases appeared to be concentrated in specific professions. Healthcare workers, workers in contact with animals, laboratory workers and refuse workers seem to have the highest risk of infection by a variety of pathogens. However, pathogens reported to be associated with closely related professions were different, indicating qualitative under-reporting. Arranging the results of this systematic review on work-related infectious diseases in a matrix of occupational groups and exposure pathways allowed the reliable identification of exposure hazards for specific occupational groups beyond currently reported diseases. [ABSTRACT FROM AUTHOR]

The public health effect of illness caused by foodborne pathogens in Greece during 1996-2006 was quantified by using publicly available surveillance data, hospital statistics, and literature. Results were expressed as the incidence of different disease outcomes and as disability-adjusted life years (DALY), a health indicator combining illness and death estimates into a single metric. It has been estimated that each year ≈370,000 illnesses/million inhabitants are likely caused because of eating contaminated food; 900 of these illnesses are severe and 3 fatal, corresponding to 896 DALY/million inhabitants. Ill-defined intestinal infections accounted for the greatest part of reported cases and 27% of the DALY. Brucellosis, echinococcosis, salmonellosis, and toxoplasmosis were found to be the most common known causes of foodborne illnesses, being responsible for 70% of the DALY. Overall, the DALY metric provided a quantitative perspective on the impact of foodborne illness that may be useful for prioritizing food safety management targets. [ABSTRACT FROM AUTHOR]

Background: Psychological consequences such as posttraumatic stress disorder (PTSD) are currently neglected in burden-of-injury calculations. Aim: To assess the disease burden of PTSD due to unintentional injury and compare this health loss with physical injury consequences. Methods: From literature sources, the prevalence of PTSD at four follow-up periods (<3 months, 3--6 months, 7--12 months and >12 months) was estimated. The uncertainty of the estimated PTSD prevalence was modelled by a Bayesian approach. The prevalence rates were then linked to national data on unintentional injury, disability weights and duration to estimate the incidence and disability-adjusted life years (DALY) resulting from PTSD in addition to physical injury consequences. Results: The data suggest that PTSD prevalence among injury victims decreases over time. The average PTSD prevalence at <3 months follow-up was 21% (90% credibility interval (CI) 17% to 24%) for patients presenting at the emergency department and 30% (90% CI 27% to 33%) for patients who were hospitalised, tapering down after 12 months to 4% (90% CI 3% to 5%) and 6% (90% CI 4% to 10%), respectively. These estimates translate into 191 000 (90% CI 161 000 to 222 000) cases of PTSD per year in the Dutch population (1.2%) due to unintentional injury. Including PTSD increases the non-fatal burden of disease of unintentional injuries by 53% (from 116 000 to 178 000 DALYs (90% CI 150 000 to 217 000)). Conclusions: Ignoring PTSD in burden-of-injury studies results in a considerable underestimation of the burden of injury. This may affect resource allocation and the identification of important prevention priorities. [ABSTRACT FROM AUTHOR]

The current article describes the economic evaluation of interventions to control Campylobacter on chicken meat by means of a cost-utility analysis. Apart from the methodology used, the main focus of this article is on data gaps and assumptions made, and their impact on results and conclusions. The direct intervention costs, the relative risk, the disease burden (expressed in disability-adjusted life years (DALYs)), and the costs of illness for the various interventions are necessary inputs for the cost-utility analysis. The cost-utility ratio (CUR)—the measure for efficiency—is expressed in net costs per avoided DALY. Most data gaps were of a biological order, but for some interventions, information on costs was also scarce. As a consequence, assumptions had to be made, which had some impact on the estimated CUR. A higher (lower) incidence of Campylobacter infections associated with chicken meat, higher (lower) effectiveness, and lower (higher) intervention costs, respectively, would result in absolute better (worse) CUR estimates. By taking the perspective of all consumers eating Dutch chicken meat, rather than only the Dutch society, absolute better CUR estimates could be obtained. Indirect costs or a shift toward non-Dutch chicken meat would both result in higher CUR estimates. Despite the assumptions made, three interventions showed for most of the applied sensitivity analyses relatively favorable CUR estimates: limiting fecal leakage during processing, carcass decontamination by dipping in a chemical solution, and the phage therapy. However, all three do have some clauses. [ABSTRACT FROM AUTHOR]

The goal of the CARMA (Campylobacter risk management and assessment) project was to advise the Dutch government on the effectiveness and efficiency of interventions aimed at reducing campylobacteriosis cases in the Netherlands. The burden of disease, expressed in Disability-Adjusted Life Years (DALYs) and the corresponding cost-of-illness, were estimated using data from epidemiological studies. With the help of a risk assessment model, the reduction in the incidence of Campylobacter infections due to a set of possible interventions in the broiler meat (chicken) chain was modeled. Separately, costs related to the implementation of these interventions in the broiler meat chain were estimated. For each intervention to be modeled, the net costs of an intervention—additional costs in the broiler meat chain minus reduced cost-of-illness—were related to the reduced burden of disease. This resulted in a cost-utility ratio, expressing the relative efficiency of several policy options to reduce Campylobacter infections. [EconLit Citations: Q180, I180] © 2007 Wiley Periodicals, Inc. Agribusiness 23: 173–192, 2007. [ABSTRACT FROM AUTHOR]

Studies the applicability of disability adjusted life-years (DALY) to measure the health effects of drinking water disinfection. Comparison of the risk of infection by ozonation of water to risk of cancer from bromate; Calculation of health benefits in DALY; Uncertainty on the application of DALY.

BACKGROUND: The Global Burden of Disease (GBD) study assesses health losses from diseases, injuries, and risk factors using disability-adjusted life-years, which need a set of disability weights to quantify health levels associated with non-fatal outcomes. The objective of this study was to estimate disability weights for the GBD 2013 study. METHODS: We analysed data from new web-based surveys of participants aged 18-65 years, completed in four European countries (Hungary, Italy, the Netherlands, and Sweden) between Sept 23, 2013, and Nov 11, 2013, combined with data previously collected in the GBD 2010 disability weights measurement study. Surveys used paired comparison questions for which respondents considered two hypothetical individuals with different health states and specified which person they deemed healthier than the other. These surveys covered 183 health states pertinent to GBD 2013; of these states, 30 were presented with descriptions revised from previous versions and 18 were new to GBD 2013. We analysed paired comparison data using probit regression analysis and rescaled results to disability weight units between 0 (no loss of health) and 1 (loss equivalent to death). We compared results with previous estimates, and an additional analysis examined sensitivity of paired comparison responses to duration of hypothetical health states. FINDINGS: The total analysis sample consisted of 30 230 respondents from the GBD 2010 surveys and 30 660 from the new European surveys. For health states common to GBD 2010 and GBD 2013, results were highly correlated overall (Pearson's r 0·992 [95% uncertainty interval 0·989-0·994]). For health state descriptions that were revised for this study, resulting disability weights were substantially different for a subset of these weights, including those related to hearing loss (eg, complete hearing loss: GBD 2010 0·033 [0·020-0·052]; GBD 2013 0·215 [0·144-0·307]) and treated spinal cord lesions (below the neck: GBD 2010 0·047 [0·028-0·072]; GBD 2013 0·296 [0·198-0·414]; neck level: GBD 2010 0·369 [0·243-0·513]; GBD 2013 0·589 [0·415-0·748]). Survey responses to paired comparison questions were insensitive to whether the comparisons were framed in terms of temporary or chronic outcomes (Pearson's r 0·981 [0·973-0·987]). INTERPRETATION: This study substantially expands the empirical basis for assessment of non-fatal outcomes in the GBD study. Findings from this study substantiate the notion that disability weights are sensitive to particular details in descriptions of health states, but robust to duration of outcomes., Version of Record

Background: Globally, foodborne diseases result in a significant disease burden with low- and middle-income countries disproportionately affected. Estimates of healthcare costs related to foodborne disease can aid decision makers to take action to mitigate risks and prevent illness. However, only limited data on the African continent are available, especially related to more severe sequelae. We provide estimates of direct and indirect (non)-medical costs of patients with diarrhoea, Guillain-Barré syndrome (GBS), and invasive non-typhoidal salmonellosis (iNTS) in three healthcare facilities in Gondar, Ethiopia.Methods: We used healthcare data from patient records, interviews with family caregivers and 2020 healthcare resource unit costs. Descriptive statistical analysis was performed. For diarrhoea, differences in mean and median transformed costs between healthcare facilities and etiologies (Campylobacter spp., enterotoxigenic Escherichia coli, non-typhoidal Salmonella enterica) were analysed with ANOVA and chi squared tests. Contribution of healthcare facility, dehydration severity, sex, age and living area to transformed costs was identified with linear regression. Results are in 2020 USD per patient. To extrapolate to national level, 2017 national incidence estimates were used.Results: Mean direct medical costs were 8.96 USD for diarrhoea (health centre 6.50 USD, specialised hospital 9.53 USD, private clinic 10.56 USD), 267.70 USD for GBS, and 47.79 USD for iNTS. Differences in costs between diarrhoea patients were mainly associated with healthcare facility. Most costs did not differ between etiologies. Total costs of a diarrhoea patient in the specialised hospital were 67 USD, or 8% of gross national income per capita. For direct medical plus transport costs of a GBS and iNTS patient in the specialised hospital, this was 33% and 8%, respectively. Of the 83.9 million USD estimated national non-typhoidal Salmonella enterica related cost, 12.2% was due to iNTS, and of 187.8 million USD related to Campylobacter spp., 0.2% was due to GBS.Conclusion: Direct medical costs per patient due to GBS and iNTS were 30 respectively five times those due to diarrhoea. Costs of a patient with diarrhoea, GBS or iNTS can be a substantial part of a household's income. More severe sequalae can add substantially to cost-of-illness of foodborne hazards causing diarrheal disease. [ABSTRACT FROM AUTHOR]

Globally, two billion people suffer from micronutrient deficiencies, 151 million children under five suffer from stunting, and millions more have impaired cognitive development related to poor nutrition. This is partly due to insufficient consumption of animal-sourced foods (ASF), which supply multiple bioavailable nutrients that are lacking in the cereal-based diets of the poor. Yet, reports like the one recently published by the EAT-Lancet Commission, solely focus on the threat of ASF consumption on sustainability and human health, overestimate and ignore the tremendous variability in the environmental impact of livestock production, and fail to adequately include the experience of marginalized women and children in low- and middle-income countries whose diets regularly lack the necessary nutrients. Yet animal-source foods have been described by the World Health Organization as the best source of high-quality nutrient-rich food for children aged 6–23 months. Livestock and ASF are vital to sustainability as they play a critical role in improving nutrition, reducing poverty, improving gender equity, improving livelihoods, increasing food security, and improving health. The nutritional needs of the world's poor, particularly women and children, must be considered in sustainability debates. • Animal source foods are necessary and missing in the diets of nearly 800 million individuals. • ASF are the best source of high-quality nutrient-rich food for children aged 6–23 months. • Negative impacts of livestock and ASF on human and planetary health are overstated. • Sustainable development must consider needs of the poorest and most vulnerable. [ABSTRACT FROM AUTHOR]

Background: According to the World Health Organization, 600 million cases of foodborne disease occurred in 2010. To inform risk management strategies aimed at reducing this burden, attribution to specific foods is necessary. Objective: We present attribution estimates for foodborne pathogens (Campylobacter spp., enterotoxigenic Escherichia coli (ETEC), Shiga-toxin producing E. coli, nontyphoidal Salmonella spp., Cryptosporidium spp., Brucella spp., and Mycobacterium bovis) in three African countries (Burkina Faso, Ethiopia, Rwanda) to support risk assessment and cost-benefit analysis in three projects aimed at increasing safety of beef, dairy, poultry meat and vegetables in these countries. Methods: We used the same methodology as the World Health Organization, i.e., Structured Expert Judgment according to Cooke's Classical Model, using three different panels for the three countries. Experts were interviewed remotely and completed calibration questions during the interview without access to any resources. They then completed target questions after the interview, using resources as considered necessary. Expert data were validated using two objective measures, calibration score or statistical accuracy, and information score. Performance-based weights were derived from the two measures to aggregate experts' distributions into a so-called decision maker. The analysis was made using Excalibur software, and resulting distributions were normalized using Monte Carlo simulation. Results: Individual experts' uncertainty assessments resulted in modest statistical accuracy and high information scores, suggesting overconfident assessments. Nevertheless, the optimized item-weighted decision maker was statistically accurate and informative. While there is no evidence that animal pathogenic ETEC strains are infectious to humans, a sizeable proportion of ETEC illness was attributed to animal source foods as experts considered contamination of food products by infected food handlers can occur at any step in the food chain. For all pathogens, a major share of the burden was attributed to food groups of interest. Within food groups, the highest attribution was to products consumed raw, but processed products were also considered important sources of infection. Conclusions: Cooke's Classical Model with performance-based weighting provided robust uncertainty estimates of the attribution of foodborne disease in three African countries. Attribution estimates will be combined with country-level estimates of the burden of foodborne disease to inform decision making by national authorities. Author summary: The World Health Organization has presented estimates of the burden of foodborne disease and attribution percentages of zoonotic foodborne pathogens to food groups (e.g., beef, vegetables,..). To inform food safety decision making at the national level, these estimates should be combined, extended to pathogens with human reservoirs and provided at a more detailed level (e.g., drinking raw milk as one food product in the dairy group). We present a Structured Expert Elicitation study using the same protocol as the World Health Organization (Cooke's Classical Model) to attribute foodborne disease of selected pathogens (Campylobacter spp., enterotoxigenic Escherichia coli, Shiga-toxin producing E. coli, nontyphoidal Salmonella spp., Cryptosporidium spp., Brucella spp., Mycobacterium bovis) to different food types and food products in the beef, dairy, poultry and vegetable groups in three African countries (Burkina Faso, Ethiopia, and Rwanda). Individual experts' uncertainty assessments resulted in modest statistical accuracy and high information scores, that is concentrated in small ranges, suggesting overconfident assessments. Nevertheless, the optimized item-weighted decision maker was statistically accurate and informative. Cooke's Classical Model with performance-based weighting provided robust uncertainty estimates of the attribution of foodborne disease in three African countries. [ABSTRACT FROM AUTHOR]

Background: The Girinka program in Rwanda has contributed to an increase in milk production, as well as to reduced malnutrition and increased incomes. But dairy products can be hazardous to health, potentially transmitting diseases such as bovine brucellosis, tuberculosis, and cause diarrhea. We analyzed the burden of foodborne disease due to consumption of raw milk and other dairy products in Rwanda to support the development of policy options for the improvement of the quality and safety of milk. Methods: Disease burden data for five pathogens (Campylobacter spp., nontyphoidal Salmonella enterica, Cryptosporidium spp., Brucella spp., and Mycobacterium bovis) were extracted from the 2010 WHO Foodborne Disease Burden Epidemiology Reference Group (FERG) database and merged with data of the proportion of foodborne disease attributable to consuming dairy products from FERG and a separately published Structured Expert Elicitation study to generate estimates of the uncertainty distributions of the disease burden by Monte Carlo simulation. Results: According to WHO, the foodborne disease burden (all foods) of these five pathogens in Rwanda in 2010 was like or lower than in the Africa E subregion as defined by FERG. There were 57,500 illnesses occurring in Rwanda owing to consumption of dairy products, 55 deaths and 3,870 Disability Adjusted Life Years (DALYs) causing a cost-of-illness of $3.2 million. 44% of the burden (in DALYs) was attributed to drinking raw milk and sizeable proportions were also attributed to traditionally (16–23%) or industrially (6–22%) fermented milk. More recent data are not available, but the burden (in DALYs) of tuberculosis and diarrheal disease by all causes in Rwanda has declined between 2010 and 2019 by 33% and 46%, respectively. Conclusion: This is the first study examining the WHO estimates of the burden of foodborne disease on a national level in Rwanda. Transitioning from consuming raw to processed milk (fermented, heat treated or otherwise) may prevent a considerable disease burden and cost-of-illness, but the full benefits will only be achieved if there is a simultaneous improvement of pathogen inactivation during processing, and prevention of recontamination of processed products. [ABSTRACT FROM AUTHOR]

Background: Estimates by the World Health Organization indicate that over 800,000 global neonatal deaths each year are attributed to deviations from recommended best practices in infant feeding. Identifying factors promoting ideal breastfeeding practices may facilitate efforts to decrease neonatal and infant death rates and progress towards achieving the Sustainable Development Goals set for 2030. Though numerous studies have identified the benefits of breastfeeding in reducing the risk of childhood undernutrition, infection and illness, and mortality in low- and middle-income countries, no studies have explored predictors of breastfeeding practices in rural eastern Ethiopia, where undernutrition is widespread. The aim of this study is to examine predictors of infant feeding practices in Haramaya, Ethiopia, using a multi-level conceptual framework. Methods: This study uses data collected from household questionnaires during the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project among 102 households in the Haramaya woreda, Eastern Hararghe Zone, Eastern Ethiopia, and investigates factors influencing breastfeeding practices: early initiation, prelacteal feeding, and untimely complementary feeding. Results: Nearly half (47.9%) of infants in this study were non-exclusively breastfed (n = 96). Generalized liner mixed effects models of breastfeeding practices revealed that prelacteal feeding may be a common practice in the region (43.9%, n = 98) and characterized by gender differences (p =.03). No factors evaluated were statistically significantly predictive of early initiation and untimely complementary feeding (82% and 14%, respectively). Severely food insecure mothers had more than 72% lower odds of early breastfeeding initiation, and participants who self-reported as being illiterate had 1.53 times greater odds of untimely complementary feeding (95% CI, [0.30,7.69]) followed by male children having 1.45 greater odds of being untimely complementary fed compared to female (95% CI,[0.40,5.37]). Conclusions: This study found high rates of prelacteal feeding and low prevalence of exclusive breastfeeding, with girls more likely to be exclusively breastfed. While no predictors evaluated in this multi-level framework were associated with prevalence of early initiation or complementary feeding, rates may be clinically meaningful in a region burdened by undernutrition. Findings raise questions about gendered breastfeeding norms, the under-examined role of khat consumption on infant feeding, and the complex factors that affect breastfeeding practices in this region. This information may be used to guide future research questions and inform intervention strategies. [ABSTRACT FROM AUTHOR]

Pond irrigation water comprises a major pathway of pathogenic bacteria to fresh produce. Current regulatory methods have been shown to be ineffective in assessing this risk when variability of bacterial concentrations is large. This paper proposes using mechanistic modeling of bacterial transport as a way to identify improved strategies for mitigating this risk pathway. If the mechanistic model is successfully tested against observed data, global sensitivity analysis (GSA) can identify important mechanisms to inform alternative, preventive bacterial control practices. Model development favored parsimony and prediction of peak bacterial concentration events. Data from two highly variable surface water irrigation ponds showed that the model performance was similar or superior to that of existing pathogen transport models, with a Nash-Sutcliffe efficiency of 0.48 and 0.18 for the two ponds. GSA quantified bacterial sourcing and hydrology as the most important processes driving pond bacterial contamination events. Model analysis has two main implications for improved regulatory methods: that peak concentration events are associated with runoff-producing rainfall events and that intercepting bacterial runoff transport may be the best option to prevent bacterial contamination of surface water irrigation ponds and thus fresh produce. This research suggests the need for temporal management strategies. IMPORTANCE Preventive management of agricultural waters requires understanding of the drivers of bacterial contamination events. We propose mechanistic modeling as a way forward to understand and predict such events and have developed and tested a parsimonious model for rain-driven surface runoff contributing to generic Escherichia coli contamination of irrigation ponds in Central Florida. While the model was able to predict the timing of peak events reasonably well, the highly variable magnitude of the peaks was less well predicted. This indicates the need to collect more data on the fecal contamination inputs of these ponds and the use of mechanistic modeling and global sensitivity analysis to identify the most important data needs. [ABSTRACT FROM AUTHOR]

Illnesses transmitted by food and water cause a major disease burden in the United States despite advancements in food safety, water treatment, and sanitation. We report estimates from a structured expert judgment study using 48 experts who applied Cooke's classical model of the proportion of disease attributable to 5 major transmission pathways (foodborne, waterborne, person-to-person, animal contact, and environmental) and 6 subpathways (food handler-related, under foodborne; recreational, drinking, and nonrecreational/nondrinking, under waterborne; and presumed person-to-person-associated and presumed animal contact-associated, under environmental). Estimates for 33 pathogens were elicited, including bacteria such as Salmonella enterica, Campylobacter spp., Legionella spp., and Pseudomonas spp.; protozoa such as Acanthamoeba spp., Cyclospora cayetanensis, and Naegleria fowleri; and viruses such as norovirus, rotavirus, and hepatitis A virus. The results highlight the importance of multiple pathways in the transmission of the included pathogens and can be used to guide prioritization of public health interventions. [ABSTRACT FROM AUTHOR]

Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million-12.0 million), results in 601,000 ED visits (95% CrI 364,000-866,000), 118,000 hospitalizations (95% CrI 86,800-150,000), and 6,630 deaths (95% CrI 4,520-8,870) and incurring US $3.33 billion (95% CrI 1.37 billion-8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually. [ABSTRACT FROM AUTHOR]