Global Burden Of Foodborne Disease Research Articles

The importance of estimating the burden of disease from foodborne transmission of Trypanosoma cruzi.

Chagas disease (ChD), caused by infection with the flagellated protozoan, Trypanosoma cruzi, has a complicated transmission cycle with many infection routes. These include vector-borne (via the triatomine (reduviid bug) vector defecating into a skin abrasion, usually following a blood meal), transplacental transmission, blood transfusion, organ transplant, laboratory accident, and foodborne transmission. Foodborne transmission may occur due to ingestion of meat or blood from infected animals or from ingestion of other foods (often fruit juice) contaminated by infected vectors or secretions from reservoir hosts. Despite the high disease burden associated with ChD, it was omitted from the original World Health Organization estimates of foodborne disease burden that were published in 2015. As these estimates are currently being updated, this review presents arguments for including ChD in new estimates of the global burden of foodborne disease. Preliminary calculations suggest a burden of at least 137,000 Disability Adjusted Life Years, but this does not take into account the greater symptom severity associated with foodborne transmission. Thus, we also provide information regarding the greater health burden in endemic areas associated with foodborne infection compared with vector-borne infection, with higher mortality and more severe symptoms. We therefore suggest that it is insufficient to use source attribution alone to determine the foodborne proportion of current burden estimates, as this may underestimate the higher disability and mortality associated with the foodborne infection route.

A review of the literature of Listeria monocytogenes in Africa highlights breast milk as an overlooked human source.

According to the latest WHO estimates (2015) of the global burden of foodborne diseases, Listeria monocytogenes is responsible for one of the most serious foodborne infections and commonly results in severe clinical outcomes. The 2013 French MONALISA prospective cohort identified that women born in Africa has a 3-fold increase in the risk of maternal neonatal listeriosis. One of the largest L. monocytogenes outbreaks occurred in South Africa in 2017-2018 with over 1,000 cases. Moreover, recent findings identified L. monocytogenes in human breast milk in Mali and Senegal with its relative abundance positively correlated with severe acute malnutrition. These observations suggest that the carriage of L. monocytogenes in Africa should be further explored, starting with the existing literature. For that purpose, we searched the peer-reviewed and grey literature published dating back to 1926 to date using six databases. Ultimately, 225 articles were included in this review. We highlighted that L. monocytogenes is detected in various sample types including environmental samples, food samples as well as animal and human samples. These studies were mostly conducted in five east African countries, four west African countries, four north African countries, and two Southern African countries. Moreover, only ≈ 0.2% of the Listeria monocytogenes genomes available on NCBI were obtained from African samples, contracted with its detection. The pangenome resulting from the African Listeria monocytogenes samples revealed three clusters including two from South-African strains as well as one consisting of the strains isolated from breast milk in Mali and Senegal and, a vaginal post-miscarriage sample. This suggests there was a clonal complex circulating in Mali and Senegal. As this clone has not been associated to infections, further studies should be conducted to confirm its circulation in the region and explore its association with foodborne infections. Moreover, it is apparent that more resources should be allocated to the detection of L. monocytogenes as only 15/54 countries have reported its detection in the literature. It seems paramount to map the presence and carriage of L. monocytogenes in all African countries to prevent listeriosis outbreaks and the related miscarriages and confirm its association with severe acute malnutrition.

Microbial Contamination of Ready-To-Eat Fresh Produce by Human Enteric Pathogens: The Global Burden of Foodborne Diseases

Microbial Contamination of Ready-To-Eat Fresh Produce by Human Enteric Pathogens: The Global Burden of Foodborne Diseases

Research progress on detection techniques for point-of-care testing of foodborne pathogens.

The global burden of foodborne disease is enormous and foodborne pathogens are the leading cause of human illnesses. The detection of foodborne pathogenic bacteria has become a research hotspot in recent years. Rapid detection methods based on immunoassay, molecular biology, microfluidic chip, metabolism, biosensor, and mass spectrometry have developed rapidly and become the main methods for the detection of foodborne pathogens. This study reviewed a variety of rapid detection methods in recent years. The research advances are introduced based on the above technical methods for the rapid detection of foodborne pathogenic bacteria. The study also discusses the limitations of existing methods and their advantages and future development direction, to form an overall understanding of the detection methods, and for point-of-care testing (POCT) applications to accurately and rapidly diagnose and control diseases.

Food safety surveillance in Bhutan, conducted from 2019 to 2021

Food-borne diseases are caused by a wide range of microbiological and chemical or toxins with different levels of severity, which range from mild sickness to life-threatening illness. The World Health Organization estimates that the global burden of foodborne diseases is 420000 mortality and at least 1 in 10 people falls ill every year from eating contaminated food. African and South-East Asia Regions have the highest burden of foodborne diseases. Several devastating outbreaks of foodborne diseases have been reported in Bhutan. This report presents the food safety surveillance data for food samples collected between June 2019 to December 2021 from five Districts (Paro, Thimphu, Phuentsholing, Gelephu and Monggar). Ready-to-eat food samples were collected by Food inspectors and samples were shipped to Royal Centre for Disease Control (RCDC) maintaining a cold chain during transportation. The results show that 12.36% (n=78) of food samples were nonacceptable due to indicator test organism contamination and 8.71% (n=55) of the RTE food samples were unacceptable due to the presence of the pathogenic organism. The common type of pathogen isolated was Staphylococcus aureus, and Bacillus cereus, and low detection of Aeromonas and Shigella spp. The seasonality pattern of food contamination shows that most contamination occurred higher during hot and wet seasons. The findings demonstrate that RTE is likely to cause foodborne illness. Therefore, education on personal hygiene, good manufacturing practices and food safety aspect would improve food quality thereby reducing the incidence of foodborne incidences.

Microfluidic devices for multiplexed detection of foodborne pathogens

The global burden of foodborne diseases is substantial and foodborne pathogens are the major cause for human illnesses. In order to prevent the spread of foodborne pathogens, detection methods are constantly being updated towards rapid, portable, inexpensive, and multiplexed on-site detection. Due to the nature of the small size and low volume, microfluidics has been applied to rapid, time-saving, sensitive, and portable devices to meet the requirements of on-site detection. Simultaneous detection of multiple pathogens is another key parameter to ensure food safety. Multiplexed detection technology, including microfluidic chip design, offers a new opportunity to achieve this goal. In this review, we introduced several sample preparation and corresponding detection methods on microfluidic devices for multiplexed detection of foodborne pathogens. In the sample preparation section, methods of cell capture and enrichment, as well as nucleic acid sample preparation, were described in detail, and in the section of detection methods, amplification, immunoassay, surface plasmon resonance and impedance spectroscopy were exhaustively illustrated. The limitations and advantages of all available experimental options were also summarized and discussed in order to form a comprehensive understanding of cutting-edge technologies and provide a comparative assessment for future investigation and in-field application.

Food Safety Implications of Transitions Toward Sustainable Healthy Diets.

Despite increased political attention, foodborne diseases still cause a substantial public health, economic, and social burden worldwide. Children younger than 5 years, people living in developing regions, and in the poorest areas of the world are disproportionally affected, bearing a large proportion of the global burden of foodborne disease. Yet, food safety is a prerequisite to ensuring food security globally: Foods that are responsible for important food safety problems are also crucial to ensure food security in some regions and are essential sources of nutrition. Moreover, together with calls for action to meeting international sustainable development goals, global efforts to promote food security and healthy diets have now highlighted the need to modify food systems globally. This article therefore explores the food safety dimensions of transitions toward food systems that promote sustainable healthy diets. The current body of evidence points to the combined health and environmental benefits of shifting toward a more plant-based diet, including vegetables and fruits, nuts, pulses, and whole grains. As a shift toward more plant-based diets may also lead to higher exposures to chemicals or pathogens present in these foods, an evaluation of food safety implications of such transitions is now imperative. We conclude that several synergies between public health, environmental, and food safety strategies can be identified to support dietary transitions.

Increasing incidence of invasive nontyphoidal Salmonella infections in Queensland, Australia, 2007–2016

Nontyphoidal Salmonella is a major contributor to the global burden of foodborne disease, with invasive infections contributing substantially to illnesses and deaths. We analyzed notifiable disease surveillance data for invasive nontyphoidal Salmonella disease (iNTS) in Queensland, Australia. We used Poisson regression to estimate incidence rate ratios by gender, age group, and geographical area over 2007–2016. There were 995 iNTS cases, with 945 (92%) confirmed by blood culture. Salmonella Virchow accounted for 254 (25%) of 1,001 unique iNTS isolates. Invasive NTS disease notification rates peaked among infants, during the summer months, and in outback Queensland where the notification rate (95% CI) was 17.3 (14.5–20.1) cases per 100,000 population. Overall, there was a 6,5% annual increase (p<0.001) in iNTS disease incidence. In conclusion, high iNTS rates among males, infants, and the elderly require investigation of household level risk factors for NTS infection. Controlling Salmonella Virchow infections is a public health priority.

Enabling digitisation to reduce risk in the food system

Enabling digitisation to reduce risk in the food system

Capacity building and support from international organizations

Abstract WHO has a critical role to provide the evidence for action to improve food safety and to support Member states to effectively collect, analyse, report and use data on foodborne diseases. In 2006, WHO launched the initiative to estimate the global burden of foodborne diseases. The estimates were published in 2015 and showed that every year, 31 selected food-associated hazards contribute to 600 million people falling ill and 420,000 people dying because of contaminated food. About 40% of the burden was borne by children under 5 years of age. Due to limitations of diseases surveillance systems and the fact that not all ill people seek medical care, the estimated burden is recognised to be only the 'tip of the iceberg'. The actual burden is expected to be significantly higher. In line with global and regional action frameworks and based on country support plans and biennial collaboration agreements with Member States, WHO, in collaboration with its partners and collaborating centres, provides technical assistance to Member States to strengthen national food safety systems. This includes technical assistance to generate, collect and analyse food safety information underpinning evidence. Information about the burden of foodborne diseases is important to inform policy, guide resource allocation and to determine potential prevention and control measures for food safety. Acknowledging that most food safety policy work takes place at country level, WHO is developing tools for Member States to estimate the national burden of foodborne diseases. The tools are being developed to build capacity in Member States to collect, analyse and use foodborne disease data, prioritize specific food safety issues, identify risk factors in foodborne diseases and provide a baseline against which future food safety interventions can be evaluated.

Biogenic Amines and Aflatoxins in Some Imported Meat Products: Incidence, Occurrence, and Public Health Impacts

Background. Since the beginning of humanity, the global burden of foodborne disease has had a decimating effect on populations, with biogenic amines (BAs) and aflatoxins in meat products implicated. While many developed countries have legitimized safety levels for BAs using evidence-based guidelines to attain high food quality standards for consumers of meat products, developing countries are still battling against poor food quality checking. Purpose. This study examines the level of health risk of biogenic amines and aflatoxin in meat products by extracting and estimating their residues and determining their indices as a way of monitoring the potential health impacts of these residues on consumers of meat products. Methods. A total of 40 imported meat products sampled and randomly collected, representing imported luncheon meat, hot dog sausages, corned beef, and minced meat. Using recommended laboratory protocols, eight residues of BAs and aflatoxins were extracted. Results. Eight BAs, histamine, tyramine, tryptamine, cadaverine, putrescine, β-phenyl ethylamine, spermine, and spermidine, were extracted and determined in all tested samples. Tyramine levels in luncheon meat were found to be significantly higher than in other meat products, while significantly high cadaverine levels were reported in corned beef samples. The results of biogenic amine index (BAI) revealed that the quality of imported minced meat and imported hot dog samples was good (BAI &lt; 5 mg/kg), while imported luncheon meat and imported corned beef samples remained acceptable (BAI 5–20 mg/kg). Aflatoxin B1 (AFB1) was detected higher than the permissible limit (&gt;5 µg/kg) in imported luncheon meat and imported hot dog meat samples. Conclusion. The general results indicate that testing meat products for biogenic amines and aflatoxins is a very good indicator for monitoring the freshness and quality of meat products.

132. Epidemiology, Antimicrobial Resistance and Predictors of Typhoidal and Non-Typhoidal Salmonella Bacteremia in Victoria, Australia

BackgroundSalmonella species are major contributors to the global burden of foodborne disease. While typhoidal salmonella (TS) is typically associated with travel in high-income settings, non-typhoidal salmonella (NTS) is more commonly associated with locally acquired diarrhoeal disease. We aimed to assess the epidemiology, antimicrobial resistance (AMR) patterns, and clinical markers of Salmonella bloodstream infections (BSI) in Victoria, Australia.MethodsWe conducted a retrospective audit of blood culture results over a 5.5-year period at a large, private pathology provider, in Victoria, Australia. All Salmonella isolates detected in blood between January 2013 and June 2018 were included. Epidemiological, microbiological, AMR and clinical data were extracted from the pathology record and collated for analysis.ResultsOf 27,546 positive blood cultures, 262 were positive for Salmonella spp. (rate 9.51 per 1,000 positive cultures) in 187 episodes. 113 (60%) were NTS (47.8% S. Typhimurium, 9.7% S. Enteritidis), while 74 (40%) were TS (59% S. Typhi, 41% S. Paratyphi). Patients with TS were younger (median age 29 vs. 65, P < 0.0001), more likely to have traveled [OR 125 (95% CI 28.47, 549], but fewer had a positive stool [OR 0.21 (95% CI 0.08–0.58)] than those with NTS. NTS was associated with a higher median CRP (149 vs. 83, P < 0.001) and more frequently associated with an abnormal white cell count (39% vs. 18%, P = 0.003). Quinolone non-susceptibility was stable with time, and occurred more frequently in TS than NTS (71 vs. 23%, P < 0.0001). Non-susceptibility to Azithromycin was also common in TS (42%), and increasing with time (P = 0.02). Non-susceptibility to ≥1 antibiotic occurred in 54 (73%) of TS, while 24 (32%) had non-susceptibility ≥2. Ceftriaxone resistance occurred infrequently in both NTS and TS (2 vs. 0%, P = 0.5).ConclusionSalmonella is an uncommon cause of BSI in our setting, with similar proportions of TS and NTS. Typhoidal isolates were more likely to be associated with travel, and antimicrobial resistance. Despite this, ceftriaxone remains a reliable option for first-line therapy for both TS and NTS. Quinolone resistance remains common, while Azithromycin resistance has increased with time in TS.Disclosures All authors: No reported disclosures.

The FAO/WHO International Food Safety Authorities Network in Review, 2004-2018: Learning from the Past and Looking to the Future.

Contemporary patterns of global food trade necessitate cross-border communication between government authorities when unsafe food enters international commerce. The Food and Agriculture Organization of the United Nations (FAO)/World Health Organization (WHO) International Food Safety Authorities Network (INFOSAN), established in 2004, facilitates urgent communication between >600 members from 188 of the 194 FAO and WHO Member States around the world and supports the strengthening of food safety systems in an effort to mitigate the global burden of foodborne disease. For nearly 15 years, INFOSAN has been operating as a global, virtual community of practice (CoP), fostering knowledge transfer and exchange between members, and enabling crucial international communication during food safety emergencies. During this time, a number of important partnerships have been forged, including with other networks like PulseNet International. Complementarity, and cooperation between global networks like INFOSAN and PulseNet is vital to improve the efficiency and effectiveness of global efforts to curb foodborne illness. Since 2011, detailed data related to the patterns of information exchange during 293 food safety emergencies communicated through INFOSAN have been documented systematically. An analysis of these data reveals that a relatively limited number of active members from a select group of Member States contribute the majority of information exchanged through the network. For example, nine (5%) Member States were each involved in 24 or more food safety events communicated through INFOSAN between 2011 and 2017, whereas 123 (65%) Member States were involved in three events or less, including 36 (19%) involved in none. These data also demonstrate that although the overall responsiveness of members during emergencies has improved in recent years, impediments to rapid and efficient information sharing still persist. A number of potential barriers to active participation in INFOSAN have been hypothesized, but members themselves have not been conferred with on their relative importance. As a member-driven network, future research to investigate the experiences of INFOSAN members in a rigorous and systematic manner is recommended. Such work could illuminate the specific areas in which to introduce operational shifts by the INFOSAN Secretariat, to strengthen the global CoP, increase the value of INFOSAN among members, and have a robust and meaningful impact at country level to reduce the burden of foodborne disease globally.

Global disease burden of pathogens in animal source foods, 2010.

Animal source foods (ASF) such as dairy, eggs, fish and meat are an important source of high-quality nutrients. Lack of ASF in diets can result in developmental disorders including stunting, anemia, poor cognitive and motor development. ASF are more effective in preventing stunting than other foods and promoting ASF consumption in low- and middle-income countries could help improve health, particularly among pregnant women and young children. Production and consumption of ASF are, however, also associated with potential food safety risks. Strengthening of food control systems, informed by quantitative assessments of the disease burden associated with ASF is necessary to meet global nutrition goals. We present the human disease burden associated with 13 pathogens (bacteria and parasites) in ASF, based on an analysis of global burden of foodborne disease (FBD) estimates of the WHO Foodborne Disease Burden Epidemiology Reference Group (FERG). The FBD burden of these pathogens was combined with estimates of the proportion of disease transmitted by eight main groups of ASF. Uncertainty in all estimates was accounted for by Monte Carlo simulation. In 2010, the global burden of ASF was 168 (95% uncertainty interval (UI 137–219) Disability Adjusted Life Years (DALYs) per 100,000 population, which is approximately 35% of the estimated total burden of FBD. Main pathogens contributing to this burden included non-typhoidal Salmonella enterica, Taenia solium, and Campylobacter spp. The proportion of FBD burden associated with ASF varied considerably between subregions and between countries within subregions. Likewise, the contribution of different pathogens and ASF groups varied strongly between subregions. Pathogens with a localized distribution included T. solium and fishborne trematodes. Pathogens with a global distribution included non-typhoidal S. enterica, Campylobacter spp., Toxoplasma gondii, and Mycobacterium bovis. Control methods exist for many hazards associated with ASF, and their implementation is linked to economic development and effective food safety systems.

Increasing incidence of invasive nontyphoidal Salmonella infections in Queensland, Australia, 2007-2016.

Nontyphoidal Salmonella is a major contributor to the global burden of foodborne disease, with invasive infections contributing substantially to illnesses and deaths. We analyzed notifiable disease surveillance data for invasive nontyphoidal Salmonella disease (iNTS) in Queensland, Australia. We used Poisson regression to estimate incidence rate ratios by gender, age group, and geographical area over 2007–2016. There were 995 iNTS cases, with 945 (92%) confirmed by blood culture. Salmonella Virchow accounted for 254 (25%) of 1,001 unique iNTS isolates. Invasive NTS disease notification rates peaked among infants, during the summer months, and in outback Queensland where the notification rate (95% CI) was 17.3 (14.5–20.1) cases per 100,000 population. Overall, there was a 6,5% annual increase (p<0.001) in iNTS disease incidence. In conclusion, high iNTS rates among males, infants, and the elderly require investigation of household level risk factors for NTS infection. Controlling Salmonella Virchow infections is a public health priority.

Estimates of the 2015 global and regional disease burden from four foodborne metals – arsenic, cadmium, lead and methylmercury

The impact of foodborne metals on the burden of disease has been largely overlooked, in comparison to the attention on acute diseases associated with infectious foodborne agents. Four articles in this special section describe in detail the burden of disease from foodborne lead, methylmercury, arsenic, and cadmium. Ingested lead and methylmercury are causally associated with lifelong intellectual disability. Long term ingestion of arsenic is causally associated with an increased risk of cancer. Long term ingestion of cadmium is causally associated with an increased risk of late stage chronic kidney disease. This article presents an overview of the burden of disease from these four foodborne metals and discusses them in the context of the World Health Organization's initiative to estimate the global burden of foodborne disease. The results indicate that in 2015, ingestion of arsenic, methylmercury, lead, and cadmium resulted in more than 1 million illnesses, over 56,000 deaths, and more than 9 million disability-adjusted life years (DALYs) worldwide. The greatest impact on DALYs was in the Western Pacific B subregion. All of the metals were found to have high DALYs per case in comparison with other foodborne disease agents, including infectious and parasitic agents. In addition, lead, arsenic, and methylmercury were found to have high DALYs per 100,000 population in comparison to other foodborne disease agents.

Mikotoxinok hatása az életminőségünkre

A közlemény az MTA Pécsi Területi Bizottsága (PAB) éves közgyűlésén (Pécs, 2018. február 22.) elhangzott tudományos előadás anyaga. Az élelmiszer eredetű megbetegedéseknek évente kb. 420 000 halálos áldozata van, a megbetegedések gazdasági hatása is jelentős, kb. 33 millió egészséges életév veszteséget (Disability-Adjusted Life Year, DALYs) okoz. A mikotoxinok a penészgombák szekunder anyagcsere termékei, természetes környezetszennyező anyagok, amelyeket ma még nem lehet kiiktatni az élelmiszerláncból. A közlemény adatokat mutat be takarmányok mikotoxin szennyezettségére vonatkozón, ismerteti a mikotoxinok élelmiszerbiztonsági kockázatát. Példákat szolgáltat európai országok lakosságának mikotoxin expozíciójára, vizeletmintákban biomarkerek mérése alapján. Kiemeli a multitoxikus hatások jelentőségét, az egyes mikotoxinok interakciójának bonyolultságát. A multitoxikus hatások, a módosított és kötött (maszkolt), valamint az ún. emerging mikotoxinok együttes szennyezése szükségessé teszi a folyamatos monitorozást és a határértékek időszaki felülvizsgálatát.

Global burden of late-stage chronic kidney disease resulting from dietary exposure to cadmium, 2015

Chronic exposures to cadmium (Cd) are associated with reduced glomerular filtration rate (GFR), increasing the risk of chronic kidney disease (CKD). In support of the World Health Organization (WHO)’s initiative to estimate the global burden of foodborne diseases, a risk assessment was performed to estimate the Disability-Adjusted Life Years (DALYs) due to late-stage CKD associated with dietary exposures to cadmium. Using the distribution of population GFRs, the prevalence of CKD was calculated as the proportion of humans whose GFR fall in the ranges corresponding to Stage 4 or Stage 5 CKD. The increase in the CKD prevalence due to cadmium exposure was simulated based on a previously reported pharmacokinetic model describing the relationship between dietary cadmium intake and urinary cadmium (UCd), as well as a previously published dose-response relationship between UCd and GFR. Cadmium-related incidence rate, calculated as the change in the prevalence during a one-year period, were used to compute the mortality and DALY in all WHO regions. It is estimated that dietary cadmium would result in a median of 12,224 stage 4 and stage 5 new CKD cases per year worldwide, resulting in 2064 global deaths and 70,513 DALYs. These data translate into a median global burden of 1.0 DALY per 100,000 population, which account for 0.2% of the global DALYs of CKD. While these results suggest that the overall impact of dietary cadmium exposure on global CKD is low, they do indicate that reasonable efforts to reduce dietary exposure will result a positive public health impact. This would be particularly the case in areas with elevated levels of dietary cadmium.

Bacteriological quality of fresh produce and link to water and sanitation service access from informal markets in Mzuzu, Malawi

In 2010, the global burden of foodborne diseases was 33 million Disability-adjusted life years, and 40 % of this burden was for children under 5 years old (Havelaar et al. 2015). Our study site was informal public markets within Mzuzu, Malawi, visited between September and December 2015, during the dry season. From these markets, fresh vegetables, leafy greens (n = 85), tomato (n = 85), and green pepper (n = 35) were analyzed for Escherichia coli. The prevalence of E. coli was highest on leafy greens; it was found in 74 (87 %) of the 85 samples. The prevalence of E. coli in green peppers was found in 2 (6 %) of the 35 samples. The prevalence of E. coli was lowest on tomatoes; it was found in only 1 (1 %) of the 85 samples. The lack of adequate water and sanitation infrastructure in market areas may be contributing to the bacteriological contamination of fresh produce. Providing venders with free access to market area toilets containing hand-washing facilities with soap and wash water with a chlorine solution may reduce bacterial contamination of fresh produce. Universal and sustainable access to water and sanitation services must include informal public market areas to reduce diarrheal diseases transmitted through food within Sub-Saharan Africa countries.

Microbiological risk assessment

Microbiological risk assessment is defined by the CODEX Alimentarius Commission as ‘a scientifically based process consisting of the following steps: (i) hazard identification; (ii) hazard characterisation; (iii) exposure assessment; and (iv) risk characterisation’. It is one of the components of microbiological risk analysis, which has the overall objective to minimise food-borne risks to consumers. It is a complex discipline that continues to evolve and challenges and new opportunities were discussed during the breakout session ‘Microbiological risk assessment’ held at the EFSA 2nd Scientific Conference ‘Shaping the Future of Food Safety, Together’ (Milan, Italy, 14–16 October 2015). Discussions focussed on the estimation of the global burden of food-borne disease, the prioritisation of microbiological risks taking into account uncertainty, the challenges in risk assessment when dealing with viruses, the contribution of typing methods to risk assessment and approaches to deal with uncertainty in risk assessment in emergency situations. It was concluded that the results of the global burden of food-borne disease study provide, for the first time, a comprehensive comparison of risks due to different hazards and this will be an important input to food safety strategies at the global, regional and national levels. Risk ranking methodologies are an important tool for priority setting. It is important to consider the underestimation (e.g. due to bias in reporting). Typing methods for microbial hazards inevitably impact on risk assessment and can have an important influence on the accuracy of source attribution studies. Due to their high genetic diversity and the limitations of current diagnostic methods, it is still challenging to obtain robust evidence for food-borne outbreaks caused by viruses and more research is needed on the use of whole genome sequencing in this area. The lessons learnt from the recent enterohaemorrhagic Escherichia coli (EHEC) outbreak in Germany include the need for more effective and timely connections within and between institutions as responses unfold.