Health impact, food safety assessment and mitigation –
experience from a case study in the region
Seminar at Gadjah Mada University, Faculty of Veterinary Medicine
Yogyakarta, 5 August 2019
Fred Unger & Hung Nguyen-Viet
International Livestock Research Institute

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

6
FBD- a new priority – most from livestock
Millions DALYs lost per year (global)
Havelaar et al., 2015
• 31 hazards
• Worldwide
• 5 years period, various experts
WHO – Global estimates of food borne diseases burden
• Helminthes
• Microbes
• Toxins
• Aflatoxins
?¿: Most important among these 4?

7
FBD- a new priority – most from livestock
Millions DALYs lost per year (global)
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
18,000,000
20,000,000
Asia Africa Other
developing
Developed
Other toxins
Aflatoxins
Helminths
Microbial
Havelaar et al., 2015
31 hazards
• 600 mio illnesses
• 420,000 deaths
• 33 million DALYs
WHO – Global estimates of FBD burden

GLOBAL BURDEN OF FBD BURDEN,
REGIONAL DIFFERENCES
Africa America
Eastern
Mediterranean Europe
Southeast
Asia
Western
Pacific
Havelaar et al., 2018

FBD burden is a significant (and growing) public
health problem in emerging Asia
China Indonesia Laos Malaysia Myanmar Philippines Thailand Vietnam
Tuberculosis
(2016)
148 1514 1820 146 1716 1063 299 414
HIV/AIDS
(2016)
67 900 337 1080 904 25 1205 440
Malaria
(2016)
1 50 36 1 31 3 3 1
Food-borne
disease
(2010)
272 693 933 293 711 293 685 390
WHO Statistics
Comparative Public Health Burden:
Disability Adjusted Life Years Lost Per 100,000
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-
diseases/ferg/en/
• PLOS collection
http://collections.plos.org/ferg2015
• Interactive tools
https://extranet.who.int/sree/Reports?op=vs&path=/WHO_H
Q_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
Assessment
Risk
Management
Risk
Communication
*Science based *Policy based
*Interactive exchange of
information and opinions
concerning risks

Risk assessment
Codex Alimentarius Commission framework for food safety risk assessment, adapted by Grace
et al.

Risk characterization
• An estimate of the likelihood and
severity of the “negative”effect which
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
identification
Exposure
assessment
Hazard
characterization
Risk
characterization

• Uncertainty: Lack of knowledge
– Associated with the data themselves
• 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
Hazard
identification
Exposure
assessment
Hazard
characterization
Risk
characterization
Risk characterization

PROBABILITY/CONSEQUENCE MATRIX
High Negligible Very low Low Moderate High Extreme
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
PROBABILITY Risk characterization
(qualitative risk assessment)

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)
Research questions
Is pork safe in Vietnam?
Methods:
Quantitative and qualitative risk assessment
Assess cost of FBD illness (hospitalisation)
Cross-contamination Salmonella (household)
• Interdisciplinary team
• Risk based approach
• Food safety hazards:
– Biological and chemical
Research questions
What are faesable options for safer Pork?
Methods:
Food safety (FS) performance of value chain
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 characterisation
• Magnitude of the risk
Risk management

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

Results from risk assessment
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
Miss-perception towards risk – public most concerned on chemical
hazards but major health risk related to microbiological hazards
Risk for pork consumer: 1 – 2 person from 10 (17%) estimated to suffer
Salmonella caused FBD annually
Chemical risk assessment: Risk due to chemical hazards is low (heavy
metals, grow promoters and antibiotics) low – overwhelming majority of
meat samples negative tested

Investments in FS can save lives and $$$
• 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
Potential health impact – FBD Vietnam
Hospitalization costs of foodborne diarrhoea per treatment episode and
per day: USD 107 and USD 34 respectively

Other results
• Poor food safety (FS) outcomes across all retail types
• 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.
Traditional/
wet market (80%)
Street food Canteens „Organic“ food
chains, niche but
emerging
Supermarket/
convienient stores
Native pigs,
niche market, „safe
by nature

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 pilot trial also demonstrated that technical
solutions must go along with behaviour
change of butchers and require incentive
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.

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

38
FBD- a new priority – most from livestock
Millions DALYs lost per year (global)
Safe PORK
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):
• Interventions evaluated and scaled

• 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
Overall conclusions

Group work
Please discuss the food safety situation
in Jogjakarta and propose:
• 3 top concerns and identify
• 3 top hazards in food safety

This presentation is licensed for use under the Creative Commons Attribution 4.0 International Licence.
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