Food PoisoningNutritional Problems In Pakistan: Their Control And Prevention

Food Poisoning
Nutritional Problems In
Pakistan: Their Control And
Prevention
Dr. Sindhu Almas
Lecturer Community Medicine
Department, LUMHS Jamshoro.

World Health Organization. World Water Day 2001, Disease fact sheet: Diarrhoea.Geneva: WHO 2000.
According to WHO, foodborne diseases are
mounting up at an alarming rate, causing
significant impediment to socio-economic
development of a country. Food based
outbreak causes mortality of 2.2 million that
contributes 4% of all deaths each year
worldwide.

Barr W, et al. (2014). Acute diarrhea in adults.
aafp.org/afp/2014/0201/p180.html
Burden of norovirus illness and outbreaks. (2017).
cdc.gov/norovirus/php/illness-outbreaks.html
Fleisher GR, et al. (2017). Patient education: Acute diarrhea in children (beyond the basics).
uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics
Pakistan—among primitive stages of nutrition transition faces
crucial public health concerns as these outbreaks go
unreported due to poor surveillance system. Whereas,
globalization of food supply, street vendors, growing influx of
refugees, open sewages, poor sanitation and hygiene facilitate
wide dispersal of microbes into the environment amplifies the
concern.

What is food poisoning
Foodborne illness, more commonly
referred to as food poisoning, is the
result of eating contaminated, spoiled,
or toxic food. The most common
symptoms of food poisoning
include nausea, vomiting, and diarrhea.
Barr W, et al. (2014). Acute diarrhea in adults.
aafp.org/afp/2014/0201/p180.html
Burden of norovirus illness and outbreaks. (2017).
cdc.gov/norovirus/php/illness-outbreaks.html
Fleisher GR, et al. (2017). Patient education: Acute diarrhea in children (beyond the basics).
uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics

Symptoms
 Symptoms can vary depending on the source of the infection. The length of time it takes for
symptoms to appear also depends on the source of the infection, but it can range from as little as
1 hour to as long as 28 days. Common cases of food poisoning will typically include at least three
of the following symptoms:
 abdominal cramps
 diarrhea
 vomiting
 loss of appetite
 mild fever
 weakness
 nausea
 headaches
Foodborne germs and illnesses. (2016).
cdc.gov/foodsafety/foodborne-germs.html
Food poisoning. (2014).
familydoctor.org/condition/food-poisoning/
Food poisoning: Long-term effects. (n.d).
foodsafety.gov/poisoning/effects/index.html
Foods for upset stomach. (n.d.).
newhealthguide.org/Food-For-Upset-Stomach.html

Symptoms of potentially life-threatening food
poisoning include:
 diarrhea persisting for more than three days
 a fever higher than 101.5°F
 difficulty seeing or speaking
 symptoms of severe dehydration, which may include dry mouth, passing little to no
urine, and difficulty keeping fluids down
 bloody urine

What causes food poisoning?
 Most food poisoning can be traced to one of the following three major causes:
 Bacteria
 Parasites
 Viruses

Bacteria
 Bacteria is by far the most prevalent cause of food poisoning. When thinking of
dangerous bacteria, names like E. coli, Listeria, and Salmonella come to mind for
good reason. Salmonella is by far the biggest culprit of serious food poisoning
cases. According to the CDC Trusted Source, an estimated 1,000,000 cases of
food poisoning, including nearly 20,000 hospitalizations, can be traced to
salmonella infection annually. Campylobacter and C. botulinum ( botulism)are
two lesser-known and potentially lethal bacteria that can lurk in our food.

Parasites
 Food poisoning caused by parasites is not as common as food poisoning caused
by bacteria, but parasites spread through food are still very
dangerous. Toxoplasmas the parasite seen most often in cases of food poisoning.
It’s typically found in cat litter boxes. Parasites can live in your digestive tract
undetected for years. However, people with weakened immune
systems and pregnant women risk serious side effects if parasites take up
residence in their intestines.

Viruses
 Food poisoning can also be caused by a virus. The norovirus, also known as the
Norwalk virus, causes over 19 million cases of food poisoning each year. In rare
cases, it can be fatal. Sapovirus, rotavirus, and Astrovirus bring on similar
symptoms, but they’re less common. Hepatitis A virus is a serious condition that
can be transmitted through food.

How does food become contaminated?
 Pathogens can be found on almost all of the food that humans eat. However,
heat from cooking usually kills pathogens on food before it reaches our plate.
Foods eaten raw are common sources of food poisoning because they don’t go
through the cooking process.
 Occasionally, food will come in contact with the organisms in fecal matter. This
most commonly happens when a person preparing food doesn’t wash their
hands before cooking.
 Meat, eggs, and dairy products are frequently contaminated. Water may also be
contaminated with organisms that cause illness.
Guerrant RL, et al. (2001). Practice guidelines for the management of infectious diarrhea. DOI:
10.1086/318514
Mayo Clinic Staff. (2017). Food poisoning: Lifestyle and home remedies.
mayoclinic.org/diseases-conditions/food-poisoning/basics/lifestyle-home-remedies/con-20031705
Mayo Clinic Staff. (2017). Food poisoning: Risk factors.
mayoclinic.org/diseases-conditions/food-poisoning/basics/risk-factors/con-20031705

Who is at risk for food poisoning?
 Anyone can come down with food poisoning. Statistically speaking, nearly everyone
will come down with food poisoning at least once in their lives.
 There are some populations that are more at risk than others. Anyone with a
suppressed immune system or an auto-immune disease may have a greater risk of
infection and a greater risk of complications resulting from food poisoning.
 According to the Mayo Clinic, pregnant women are more at risk because their bodies
are coping with changes to their metabolism and circulatory system
during pregnancy. Elderly individuals also face a greater risk of contacting food
poisoning because their immune systems may not respond quickly to infectious
organisms. Children are also considered at-risk population because their immune
systems aren’t as developed as those of adults. Young children are more easily
affected by dehydration from vomiting and diarrhea.
Guerrant RL, et al. (2001). Practice guidelines for the management of infectious diarrhea. DOI:
10.1086/318514
Mayo Clinic Staff. (2017). Food poisoning: Lifestyle and home remedies.
mayoclinic.org/diseases-conditions/food-poisoning/basics/lifestyle-home-remedies/con-20031705
Mayo Clinic Staff. (2017). Food poisoning: Risk factors.
mayoclinic.org/diseases-conditions/food-poisoning/basics/risk-factors/con-20031705

How is food poisoning diagnosed?
 Food poisoning is often diagnosed based on a detailed history, including how
long you've been sick, your symptoms and specific foods you've eaten. A physical
examination should also be performed, looking for signs of dehydration.
 A doctor may be able to diagnose the type of food poisoning based on your
symptoms. In severe cases, blood tests, stool tests, and tests on food that you
have eaten may be conducted to determine what is responsible for the food
poisoning. doctor may also use a urine test to evaluate whether an individual is
dehydrated as a result of food poisoning.
Riddle MS, et al. (2016). ACG clinical guideline: Diagnosis, treatment, and prevention of acute diarrheal infections in adults. DOI:
10.1038/ajg.2016.126
Salmonella. (2017).
cdc.gov/salmonella/
See recent recalls. (n.d.).
foodsafety.gov/recalls/recent/index.html

Treatment
 Treatment for food poisoning typically depends on the source of the illness, if
known, and the severity of symptoms. For most people, the illness resolves
without treatment within a few days, though some types of food poisoning may
last longer.
 Treatment of food poisoning may include:
 Replacement of lost fluids: Fluids and electrolytes — minerals such as sodium,
potassium and calcium that maintain the balance of fluids in your body — lost to
persistent diarrhea need to be replaced. Some children and adults with persistent
diarrhea or vomiting may need hospitalization, where they can receive salts and
fluids through a vein (intravenously), to prevent or treat dehydration.
10.1038/ajg.2016.126
Salmonella. (2017).
cdc.gov/salmonella/

Cont.
 Antibiotics: Doctor may prescribe antibiotics if there is a certain kind of bacterial
food poisoning and symptoms are severe. Food poisoning caused by listeria needs
to be treated with intravenous antibiotics during hospitalization. The sooner
treatment begins, the better. During pregnancy, prompt antibiotic treatment may
help keep the infection from affecting the baby.
 Antibiotics will not help food poisoning caused by viruses. Antibiotics may actually
worsen symptoms in certain kinds of viral or bacterial food poisoning.
10.1038/ajg.2016.126
Salmonella. (2017).
cdc.gov/salmonella/

Prevention
 The best way to prevent food poisoning is to handle your food safely and to avoid any food that
may be unsafe.
 Some foods are more likely to cause food poisoning because of the way they’re produced and
prepared. Meat, poultry, eggs, and shellfish may harbor infectious agents that are killed during
cooking. If these foods are eaten in their raw form, not cooked properly, or if hands and surfaces
are not cleaned after contact, food poisoning can occur.
 Other foods that are likely to cause food poisoning include:
 fish products that are served raw or undercooked
 meats and hot dogs that are not heated or cooked
 ground beef, which may contain meat from several animals
 unpasteurized milk, cheese, and juice
 raw, unwashed fruits and vegetables
 Washing hands and food items before cooking.
10.1038/ajg.2016.126
Salmonella. (2017).
cdc.gov/salmonella/

How to investigate an outbreak
 It is recognized that not all settings where outbreaks occur
will have the necessary infrastructure to complete all steps
described but efforts should be made to do so. The steps are
presented in approximately chronological order but different
situations will demand changes from this order. In practice,
some steps will be carried out simultaneously, others will be
required throughout the whole process while some may not
be required at all.

If you are interested in foodborne
outbreak investigation then you should
study the following document
https://www.who.int/foodsafety/
publications/foodborne_disease/o
utbreak_guidelines.pdf

Nutritional Problems In Pakistan: Their
Control And Prevention
PROTEIN ENERGY MALNUTRITION
(PEM)
MICRONUTRIENT DEFICIENCY
CHRONIC DISEASES
EATING DISORDERS

WHO IS AT RISK??
 PREGNANT WOMEN
 LACTATING WOMEN
 INFANTS
 PRESCHOOL CHILDREN
 ADOLESCENT GIRLS
 ELDERLY

PROTEIN ENERGY MALNUTRITION
 Protein–energy malnutrition (or protein–calorie malnutrition) refers to a
form of malnutrition where there is inadequate protein and calorie intake
 It is considered as the primary nutritional problem in Pakistan
 PEM is due to the “food gap” between the intake and requirement
 Causes childhood morbidity and mortality
PROTEIN ENERGY MALNUTRITION PEM
1. KWASHIORKOR
2. MARASMUS
3. MARASMIC - KWASHIORKOR

CAUSES AND RISK FACTORS CONTRIBUTORY FACTORS
• Inadequate intake of food
• Diarrhea
• Respiratory infections
• Measles
• Intestinal worms
• Infants and pre schooler
• Poor environmental Hygiene
• Large family size
• Poor maternal health
• Failure of lactation
• Premature termination of breast
feeding
• Delayed supplementary feeding
• Use of over diluted cow’s milk

KWASHIORKOR
KWASHIORKOR is the most common
and widespread nutritional disorder in
developing countries. It is a form of
malnutrition caused by not getting
enough protein in the diet.

MARASMUS
 Marasmus is a severe form of malnutrition that consists of the
chronic wasting away of fat, muscle, and other tissues in the
body.
 Malnutrition occurs when the body does not get enough
protein and calories.
 This lack of nutrition can range from a shortage of certain
vitamins to complete starvation.
 Marasmus is one of the most serious forms of protein-energy
malnutrition (PEM) in the world

MARASMIC KWASHIORKOR
A malnutrition disease, primarily of children,
resulting from the deficiency of both calories
and protein. The condition is characterized by
severe tissue wasting, dehydration, loss of
subcutaneous fat, lethargy, and growth
retardation

PREVENTION
 Oral rehydration therapy helps to prevent dehydration caused by diarrhea
 Exclusive breast feeding for 6 months there after supplementary foods may be
introduced along with breast feeds
 Immunization for infants and children
 Nutritional supplements
 Early diagnosis and treatment
 Promotion and correction of feeding practices
 Family planning and spacing of birth
 Periodic surveillance
 Nutritional rehabilitation

LOW BIRTH WEIGHT
 A LBW newborn is any newborn with a birth weight of less than 2.5kg (including 2.499kg) regardless of gestational age
RISK FACTORS
o Maternal malnutrition
o Anemia
CAUSES
o Illness/infections
o Short maternal stature
o Very young age
o High parity
o Close birth intervals
o IUGR
o Hard physical labor during pregnancy
o Smoking

PREVENTION
 Identification of mothers at risk – malnutrition,
 heavy work load, infections, disease and high BP
 Increasing food intake of mother, supplementary feeding, distribution of iron and
folic acid tablets
 Avoidance if smoking
 Improved sanitation methods
 Improving health and nutrition of young girls
 Early detection and treatment of medical disorders – DM HTN
 Controlling infections – UTI, rubella, syphilis, malaria

MICRONUTRIENT DEFICIENCY
micronutrient deficiencies, which is
defined as a lack of
essential vitamins and minerals required
in small amounts by the body for proper
growth and development.

symptoms of nutritional deficiencies
 The symptoms of a nutritional deficiency depend on which nutrient the body lacks. However, there
are some general symptoms you might experience. These can include:
 pallor, or pale skin
 fatigue
 weakness
 trouble breathing
 unusual food cravings
 hair loss
 periods of lightheadedness
 constipation
 sleepiness
 heart palpitations

Cont.
 feeling faint or fainting
 depression
 tingling and numbness of the joints
 menstrual issues, such as missed periods or very heavy cycles
 poor concentration
 One may display all of these symptoms or only groups of them.
 Over time, most people adapt to the symptoms. This can cause the condition to go
undiagnosed.

How are nutritional deficiencies treated?
The treatment for a nutritional
deficiency depends on the type and
severity of the deficiency.
Dietary changes
Supplements
Parenteral administration

Iron deficiency
The most widespread nutritional deficiency worldwide is iron
deficiency. Iron deficiency can lead to anemia. This is a blood
disorder that causes fatigue, weakness, and a variety of other
symptoms.
Iron is found in foods such as dark leafy greens, red meat, and
egg yolks. It helps the body make red blood cells. When you’re
iron-deficient, your body produces fewer red blood cells. The
red blood cells it produces are smaller and paler than healthy
blood cells. They’re also less efficient at delivering oxygen to
tissues and organs.

According to the World Health Organization (WHO),
over 30 percent of the world’s population is anemic.
Many of these people are anemic due to iron
deficiency.
In fact, it’s the only nutritional deficiency that’s
prevalent in both developing and industrialized
countries. Iron deficiency anemia affects so many
people that it’s now widely recognized as a public
health epidemic.

Vitamin A deficiency
Vitamin A is a group of nutrients crucial for eye health and
functioning and reproductive health in men and women. It also
plays a part in strengthening the immune system against infections.
According to WHO, a lack of vitamin A is the leading cause of
preventable blindness in children. Pregnant women deficient in
vitamin A have higher maternal mortality rates as well.
Beta carotene is a nutrient that functions as an antioxidant. It’s found
in red, orange, yellow, and dark green produce. Beta carotene can
be converted to vitamin A in the body when needed.

For newborn babies, the best source of vitamin A is breast milk
 Vitamin A is found in:
milk
eggs
green vegetables, such as kale, broccoli, and spinach
orange vegetables, such as carrots, sweet potatoes, and pumpkin
reddish-yellow fruits, such as apricots, papaya, peaches, and
tomatoes

Thiamine (vitamin B-1) deficiency
 Another common nutritional deficiency occurs with thiamine, also known
as vitamin B-Thiamine is an important part of our nervous system. It also helps
our body turn carbohydrates into energy as part of our metabolism.
 A lack of thiamine can result in:
 weight loss
 fatigue
 confusion
 short-term memory loss
 Thiamine deficiency can also lead to nerve and muscle damage and can affect
the heart.

Cont.
 In the United States, thiamine deficiency is most often seen in people with excessive alcohol
use. Alcohol reduces the body’s ability to absorb thiamine, store thiamine in the liver, and
convert thiamine to a usable form. Thiamine deficiency is a common cause of Wernicke-
Korsakoff syndrome. This is a form of dementia.
 Many breakfast cereals and grain products in the United States are fortified with thiamine.
Other good sources of thiamine include:
 eggs
 legumes
 nuts
 seeds
 wheat germ

Niacin (vitamin B-3) deficiency
 Niacin is another mineral that helps the body convert food
into energy. It’s also known as vitamin B-3.
 A severe deficiency in niacin is often referred to as pellagra.
Niacin is found in most animal proteins but also in peanuts.
 Symptoms of pellagra include diarrhea, dementia, and skin
disorders. one can usually treat it with a balanced diet and
vitamin B-3 supplements.

Folate (vitamin B-9) deficiency
 Vitamin B-9 helps the body create red blood cells and produce DNA. It’s
often referred to as folate. Folate also helps brain development
and nervous system functioning. Folic acid is the synthetic form found
in supplements or fortified foods.
 Folate is especially important for fetal development. It plays a crucial role in
the formation of a developing child’s brain and spinal cord. Folate
deficiency can lead to severe birth defects, growth problems, or anemia.

Cont.
 Folate found in the following foods:
 beans and lentils
 citrus fruits
 leafy green vegetables
 asparagus
 meats, such as poultry and pork
 shellfish
 fortified grain products
 whole grains

Cont.
 While beans can provide a great amount of folate, the folate content in canned beans is about half of
what cooked, dried beans offer.
 pregnant women and women of childbearing age sometimes don’t consume enough folate for a healthy
pregnancy.
 The National Institutes of Health (NIH) recommends that women who are pregnant or who may become
pregnant consume up to 400 micrograms of folic acid each day — over and above the folate they’re
getting from food naturally — to help prevent birth defects.
 There’s also research showing that some people have genetic mutations that prevent their body from
methylation of folate, or converting it to a form the body can use. In these cases, while folate intake
might be adequate, a supplement of methylated folate may be necessary to prevent deficiency.

Cobalamin (vitamin B-12) deficiency
 Vitamin B-12 is a B vitamin that’s responsible for assisting the body in making enough
healthy red blood cells. Deficiency in this vitamin is common among people who:
 are vegans
 have had gastric surgery
 are over 60 years old
 have diabetes and take metformin (Glucophage)
 have a long history of antacid use
 lack intrinsic factor
 Intrinsic factor is a transport protein secreted by the stomach cells. It binds to B-12 and takes
it to the small intestine for absorption. This is the way the body is able to absorb and utilize
B-12.

Cont.
 Adequate calcium intake at meals is required for intrinsic factor to assist in B-12 absorption in the
small intestine.
 A deficiency in this vitamin may cause pernicious anemia. This is a type of anemia caused by a
decreased ability to absorb B-12 efficiently. Pernicious anemia is more common in people with
autoimmune disorders and inflammatory or digestive diseases.
 Symptoms of vitamin B-12 deficiency include:
 fatigue and weakness in extremities
 dizziness
 shortness of breath
 weight loss
 nausea or poor appetite
 sore, red, or swollen tongue
 pale or yellowish skin

Cont.
 Left untreated for too long, vitamin B-12 deficiency may cause irreversible damage to the nervous
system. More severe symptoms include:
 difficulty walking
 muscle weakness
 irritability
 dementia
 depression
 memory loss
 a variety of blood tests to check for vitamin B-12 deficiency. Blood tests can check for:
 levels of vitamin B-12
 methyl malonic acid
 intrinsic factor antibodies

Cont.
 Treatment may be provided in a variety of ways, including:
 increasing vitamin B-12 sources in the diet
 taking vitamin B-12 supplements
 receiving vitamin B-12 injections
 blood transfusions
 Vitamin B-12 is commonly found in red meat and animal products.
Vegetarian sources include fortified plant-based milks and nutritional yeast.

Vitamin D deficiency
 According to Harvard’s School of Public Health, about 1 billion people worldwide don’t get
enough vitamin D. People with darker skin tones are at a higher risk of vitamin D deficiency.
 Vitamin D is essential for healthy bones. It helps the body maintain the right levels of calcium
in order to regulate the development of teeth and bones. A lack of this nutrient can lead to
stunted or poor bone growth. Osteoporosis, caused by a lack of calcium and vitamin D, can
lead to porous and fragile bones that break very easily.
 Vitamin D is only found naturally in a few foods. Foods with vitamin D include:
 fish liver oils
 fatty fish
 mushrooms
 egg yolks
 liver

Cont.
Many dairy products and plant milks are fortified with vitamin D.
The best source of vitamin D is sunlight. According to the NIH,
some research suggests that 5 to 30 minutes of midday sun
exposure twice a week on the face, arms, neck, or back can
provide you with enough vitamin D.
Although recommended, sunscreen does hinder vitamin D
absorption from sunlight through the skin. Spend a few minutes
in the sun prior to sunscreen for optimal vitamin D absorption.

Calcium deficiency
 Calcium helps your body develop strong bones and teeth. It also helps your
heart, nerves, and muscles work the way they should.
 A calcium deficiency often doesn’t show symptoms right away, but it can lead
to serious health problems over time. If you aren’t consuming enough
calcium, your body may use the calcium from your bones instead. This leads
to bone loss.
 While some experts believe that calcium deficiencies may be related to low
bone mass and weakening of bones due to osteoporosis, it’s a topic of much
debate. According to WHO, evidence does support the importance of
calcium with vitamin D for bone health in older populations. Evidence is
weaker for younger populations.

Cont.
 Population study research by WHO also reveals that countries with lower calcium intake
don’t have high rates of bone diseases. But countries with higher calcium intake have higher
rates of hip fractures. In these countries, like the United States, high protein intake and lack
of exercise can contribute to poor calcium status and bone health.
 Calcium deficiency can lead to convulsions and abnormal heart rhythms. These can even be
life-threatening. Postmenopausal women experience greater bone loss due to changing
hormones and have more trouble absorbing calcium.
 The best sources of calcium are:
 dairy products, such as milk, yogurt, and cheese
 calcium-set tofu
 small fish with bones
 Vegetables such as kale and broccoli also have calcium. Many cereals and grains are calcium-
fortified.

IODINE DEFICIENCY DISORDERS (IDD)
IDD leads to a much wider spectrum of disorders commencing with
the intrauterine life and extending through childhood to adult life
with serious health and social implications
DISORDERS: Goiter, Hypothyroidism, Subnormal intelligence,
Delayed motor milestones, Mental deficiency, Hearing defects,
Speech defects, Mental retardation, Neuromuscular weakness,
Endemic cretinism, Intrauterine death.
PREVENTION • Iodized salt • Iodine monitoring • Public awareness
and education COMPLICATIONS • Thyrotoxicosis • Iodide goiter •
Lymphocytic thyroiditis

CHRONIC DISEASES
 OBESITY: Obesity is an epidemic diseases, which consists of body weight
that is in excess of that appropriate for a person’s height and age
standardized to account for differences, leading to an increased risk to
health related problems
 Overweight and obesity are defined as abnormal or excessive fat
accumulation that presents a risk to health. A crude population measure of
obesity is the body mass index (BMI), a person’s weight (in kilograms)
divided by the square of his or her height (in meters). A person with a BMI of
30 or more is generally considered obese. A person with a BMI equal to or
more than 25 is considered overweight.

EATING DISORDERS
 ANOREXIA NERVOSA • Anorexia nervosa is an eating disorder characterized
by immoderate food restriction, inappropriate eating habits or rituals,
obsession with having a thin figure, and an irrational fear of weight gain, as
well as a distorted body self- perception.
 BULIMIA NERVOSA • Bulimia nervosa is an eating disorder characterized by
binge eating and purging, or consuming a large amount of food in a short
amount of time followed by an attempt to rid oneself of the food consumed
(purging), typically by vomiting, taking a laxative, diuretic, or stimulant,
and/or excessive exercise, because of an extensive concern for body weight.

Cont.
 CLINICAL MANIFESTATIONS • Amenorrhea • Obvious, rapid, dramatic weight
loss at least 15% under normal body weight[ • May engage in frequent,
strenuous, or compulsive exercise • Perception of self as overweight despite
being told by others they are too thin • Intolerance to cold and frequent
complaints of being cold. Body
 • Bradycardia or tachycardia • Depression: may frequently be in a sad, lethargic
state • Solitude: may avoid friends and family; becomes withdrawn and
secretive • Swollen joints • Abdominal distension • Halitosis (from vomiting or
starvation-induced ketosis) • Dry hair and skin, as well as hair thinning •
Fatigue • Rapid mood swings

Assignment
Write a short note on prevention and
treatment of anorexia nervosa and
bulimia nervosa.

Food PoisoningNutritional Problems In Pakistan: Their Control And Prevention

Food PoisoningNutritional Problems In Pakistan: Their Control And Prevention

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Food PoisoningNutritional Problems In Pakistan: Their Control And Prevention

Similar to Food PoisoningNutritional Problems In Pakistan: Their Control And Prevention (20)

More from DrSindhuAlmas

More from DrSindhuAlmas (20)

Recently uploaded

Recently uploaded (20)