The Future of Food Safety Communication

Jørgen Schlundt, Director of the Department of Food Safety, Zoonoses and Foodborne Diseases for the World Health Organisation, outlines the current food safety burden and suggests what can be done to open up communications.

The estimated disease burden caused by unsafe food is significant in all countries around the world. Most consumers have heard of Bovine Spongiform Encephalopathy (BSE) in the United Kingdom, about Dioxin in Belgium or about the spread of Highly Pathogenic Avian Influenza (HPAI) from Asia. Nevertheless, food safety authorities in many countries often like to point out that these events – highly publicized as they might be – do not really reflect the food safety reality, and have in effect caused very little disease burden even at the global level. The same authorities often use similar statements when national outbreaks caused by Salmonella, Escherichia coli O 157 or Listeria occur because of contaminated eggs, contaminated produce or contaminated ready-to-eat foods.

These authorities are right – all of the issues mentioned above have caused a relatively low disease burden when compared to the general dramatic disease burden that affects consumers in all countries continuously from unsafe food. The best estimate we have of a more comprehensive foodborne disease burden comes from the US: in 1999 a group lead by Dr Mead from the CDC published a major study estimating that one third of the US population have a case of foodborne disease every year – and this estimate was only related to disease caused by micro-organisms (Mead et al., 1999).

The facts related to the true disease burden are seldom published by authorities. We therefore seem to have a situation in many countries where the authorities correctly point out to the public, that these outbreaks are few and often result in only limited disease burden. However, these same authorities do not always seem to make serious efforts to estimate and/or publicise the true burden of foodborne disease. This true burden stems from the cases happening every day all over the world, involving almost all types of food and resulting in not only diarrhoea, but also other serious affections such as kidney and liver failure, brain and neural disorders, long-term complications, such as reactive arthritis, and cancer as well as death from any of these other conditions. These cases are occurring in situations where they are not or cannot be linked to other single cases and are referred to as sporadic cases, which clearly constitute the majority of foodborne disease cases.

Sporadic cases

A major source of international variability in reporting of foodborne diseases relates to the number of sporadic cases. Some countries report the total number of cases of a foodborne disease, including sporadic cases, while others mainly collect information on the number of outbreaks and the number of cases involved in the outbreaks. For most foodborne diseases the major part of cases are sporadic, for some diseases (e.g. disease caused by Campylobacter spp.) the disease incidence relates almost exclusively to sporadic cases.

Deeply concerned by a potentially growing foodborne disease burden, in May 2000, at the 53rd World Health Assembly, the governing body of the WHO, adopted a resolution calling upon the WHO and its member states to recognise food safety as an essential public health function. The resolution also called for the development of systems to enable a reduction of the burden of foodborne disease. Still concerned that our estimations of this burden is very poor, the WHO has, from 2007, initiated a broad estimation of the global burden of foodborne disease, a major, long-term initiative supported by many international experts. Such estimations will enable not only a more realistic communication of the problems, but also a prioritisation of problems, as well as a science-based evaluation of the effect of different types of intervention to lower the foodborne disease burden.

Economic burden

Of course foodborne diseases not only significantly affect people’s health and well-being, but they also have economic consequences for individuals, families, communities, businesses and countries. These diseases impose a substantial burden on healthcare systems and markedly reduce economic productivity. The loss of income due to foodborne disease perpetuates the cycle of poverty in poor settings. Estimating direct as well as indirect costs of foodborne disease is difficult. An estimate in the US from 1996 placed the medical costs and productivity losses of seven important foodborne diseases in a population of approximately 250 million in the range of $6.6 billion to $37.1 billion  (Buzby and Roberts, 1996). Estimates of the economic consequences of food contamination events or foodborne disease outbreaks through altered conditions affecting national food exports are not forth-coming, and only a few examples are typically presented, mostly without a clear description of the methodology used for the estimation. However, in several major single incidents the total health bill has been measured in hundreds of millions of US dollars.

When we have more accurate estimations of the real disease burden related to unsafe food, which will hopefully be in the near future, we will most likely also see calls for political interventions of a different nature as a response. But it will not be only the better estimations that will define a new situation. We will most likely also experience an increase in the reported number of foodborne disease outbreaks.

Over the last couple of years we have seen a number of major outbreaks of foodborne disease caused by Salmonella and E. coli (especially O157) in different food vehicles. Some of the major outbreaks have been in the US. Many kids, not too found of spinach, will remember the large outbreak related to spinach a couple of years ago, and just now we are in the middle of an outbreak that might be related to other vegetable foods. While the occurrence of these outbreaks might signal a change caused by changing food production systems, the more likely explanation why is that we now know how to detect these outbreaks in new and better ways by linking bacterial isolates and thereby linking human cases and their food sources together. Genetic fingerprinting (especially Pulsed Field Gel Electrophoresis) has been known for some time, but the systems to consistently use this technique to scan the outbreak landscape is relatively knew. In the US the Pulse-Net network has been instrumental in defining some of these recent outbreak.

Communication

So, these outbreaks are not really new. They have they been happening all the time, but were never registered as outbreaks, only as single, sporadic cases. This is most likely, but of course we will only know for sure when we are able to reliably assess the true disease burden. However, the pertinent point is that we will most likely experience more documented outbreaks – a certain fraction of what was earlier called sporadic cases will be realised as part of more widespread outbreaks in the future.

But, maybe even more importantly: are we ready to communicate this new situation to consumers at large? Well, judging from previous risk communication experience, we are often lacking in food safety risk communication. Going back 10-20 years (before BSE) the usual food safety authority response would be an ‘authoritative’ response, something you would have to believe in simply because you heard it from the authority and they were clearly the ones to know best. Now, one of the problems with this approach is that whenever something goes wrong, the authority will loose credibility if it is not seen to be able to explain to people what really happened – if it continues to maintain that all is well, when obviously it is not, for example. Therefore, as a result of several communication disasters, the new focus in food safety communication is to continuously work with the public to ‘restore the publics trust’. In many cases the message from expert communicators has been: make sure you maintain the trust, be open and transparent and report immediately when something goes wrong.

Now while openness, transparency and maintaining trust are clearly very important components of any communication strategy, I would suggest that this will no longer be enough in the future. When people see a clearer picture of the real disease burden, openness and transparency will no longer do the job. People, including politicians, will want to know what we are doing to tackle the problems, how will we lower the risk and when? Luckily, food safety authorities all over the world have already started work in this area some time ago. So, what can be done?

There are several major issues at the core of improving food safety and food safety systems in most parts of the world, thereby decreasing the foodborne disease risk. The most important are:

The prevention of problems have to integrate the full food production chain: From Farm to Fork, or from Boat to Throat, recognising that the critical point for efficient prevention might be at the farm for some problems or at the retail level for others. Most present food safety systems are not built according to this important principle. Such incoherence of the systems have led to inconsistency and in some cases inefficiency of food safety systems. While prevention of foodborne disease of course has to be based on good general hygienic practices, it is important to focus our efforts towards the real risks in the population. Any system to prevent efficiently foodborne disease problems should be based upon a solid evidence base. Therefore the data-gathering efforts related to food contamination and foodborne disease need to be co-ordinated. Likewise monitoring, surveillance and control efforts should be geared towards common goals. This co-ordination is missing in many food safety systems presently, leading to a very weak evidence base, potentially leading to un-informed decisions and poor political support.

An important pre-requisite for efficiency in most areas of work is the setting of realistic targets for risk reduction and the monitoring of success/failure. In the past food safety efforts have, in most cases, not been linked directly to foodborne disease risk. Compliance with existing regulation has often been the only measure of success. The lack of clearly communicated targets for disease reduction is still a major draw-back of existing food safety systems, although some countries are now initiating major risk-based, target driven efforts to improve food safety, e.g. national plans to lower the prevalence of Salmonella in food or maybe regional plans to lower the level of acrylamide in certain foods.

Most food safety authorities acknowledge that ensuring food safety must be tackled both at national and international level. At the international level, the WHO in co-operation with the FAO, has recently developed the International Food Safety Authorities Network (INFOSAN) to promote the exchange of food safety information, including information about emergencies. This development stems from serious concern expressed by the World Health Assembly in May 2002, about health emergencies posed by natural, accidental and intentional contamination of food. Therefore the development should also be seen in light of the revised International Health Regulations of WHO, regulations that oblige every member country to provide information about public health events of international concern to WHO without delay.

INFOSAN now has more than 150 participating countries and more information about this network can be found at: www.who.int/foodsafety/fs_management/infosan_archives/en/index.html

For more information Jørgon Schlundt can be reached at: World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland, T: +41 22 791 34 45, E: schlundtj@who.int

The WHO

Food safety is an important prerequisite for everyone’s health and wellbeing. Therefore the WHO focuses on food safety as part of a broader human health agenda. In the realm of food safety the WHO focuses on four major areas:

• providing the best, internationally agreed scientific advice
• developing international standards and guidelines based on the best science
• supporting countries in building technical capacity to deal with food safety efficiently
• formulating and advocating information to consumers in collaboration with multiple countries

Chemical substances

A major problem in the estimation of disease burden relates to the burden of disease cause by chemical substances in food. In many cases it is significantly more difficult to link foodborne disease to a specific chemical hazard because it is difficult to detect the chemical in the patient, often we will only detect the effect. Two examples of relevant chemical substances related to food consumption are:

Aflatoxins are toxic substances produced by certain species of fungi, from the Aspergillus family. One of the toxins causes a very significant number of human cancers globally every year, but acute exposure can also result in disease, such outbreaks have been registered in East Africa over recent years. Aflatoxin contamination of food is often related to poor storage conditions. The greatest risk for health exists in developing countries and food insufficiency can compound the problems. The significant associated health effects pervade the developing world despite the fact that these effects could be mitigated or prevented with the current state of agricultural knowledge and public health practice.

Acrylamide is a chemical that is found in certain foods that have been cooked and processed at high temperatures – above 120 degrees Celsius. Such foods include potato chips, french fries, bread, coffee etc. In 2005, JECFA (a Joint FAO/WHO Expert Committee on Food Additives and contaminants) suggested that the level of acrylamide exposure in ordinary diets may indicate a human health concern, since the compound is estimated to be genotoxic and carcinogenic. JECFA indicated that the Margin of Exposure (margin between levels consumed through food and levels causing disease in animals) is one of the lowest known for potential carcinogens in food. Therefore, appropriate efforts to reduce acrylamide concentrations in foodstuffs are essential.

Five keys to safer food

Foodborne illness is almost 100 percent preventable. The five keys to safer food at home are:
1. Use safe water and raw materials. Use safe water or treat it to make it safe; select fresh and wholesome foods; choose foods processed for safety; wash fruit and vegetables.
2. Keep clean. Wash hands before and during food preparation; clean all surfaces and equipment used for food preparation; protect kitchen areas from insects and rodents.
3. Cook food thoroughly. Cook food thoroughly, especially meat, poultry, eggs and seafood; bring foods such as soup and stews to boiling point to make sure they reach 70 degrees; for poultry and meat, make sure that juices are clear not pink.
4. Keep food at safe temperatures. Do not leave cooked food at room temperature for more than two hours; refrigerate all cooked and perishable food below five degrees; keep cooked food piping hot until served, do not thaw frozen food at room temperature.
5. Separate raw and cooked. Separate raw meat, poultry and seafood from other foods; use separate equipment and utensils, such as knives and cutting boards for handling raw foods; store food in containers to avoid contact between raw and prepared foods.