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National burden of foodborne disease (FBD) studies are useful for risk ranking and identifying priorities for food safety resource allocation. FBD are caused by microbiological and chemical hazards, which have different incidence and mortality, and lead to health-outcomes varying in severity and duration. Due to their different origins and characteristics, distinct prevention strategies can be implemented. We present the Danish initiative to estimate the burden of FBD caused by pathogens and chemicals. We describe the methodological approaches and data used, present an overview of results for the reference year 2019, and discuss lessons learned throughout more than seven years of the project. Our estimates show that the leading causes of FBD in Denmark include both pathogens and chemicals, suggesting that food safety strategies should be diversified to tackle different issues. The experiences with this national study are useful for other countries planning to implement a burden of FBD study.

Acute childhood diarrhea is one of the leading causes of childhood morbidity and mortality in sub-Saharan African countries. Entamoeba histolytica and Giardia lamblia are the common cause of childhood diarrhea in the region. However, there are only few studies on protozoa causing diarrhea in sub-Saharan African countries. This study was conducted to investigate the relative prevalence and explore risk factors of E. histolytica and G. lamblia among diarrheic children of under 5 years in a public hospital of Ethiopia. A retrospective study was conducted among diarrheic children at Hiwot Fana hospital, Ethiopia. Records of all diarrheic children less than 5 years who had sought medical treatment in the hospital from September 1, 2020 to December 31, 2022 were included. Data were collected from 1257 medical records of the children using a structured data-collection format. Data were entered into an Excel sheet and exported into SPSS version 22 for data processing and analysis. Descriptive statistical tests, Chi-square, and logistic region analysis were applied to determine predictors of protozoa infections. Of the 1257 cases, 962 (76.5%) had watery diarrhea and the remaining 239 (19.0%) had dysentery. The combined prevalence of E. histolytica and G. lamblia among diarrheic children was 11.8% (95% CI: 9.6-13.4). As the age of children increased, the frequency of these two protozoan infections was significantly increased compared to children with other causes. There were more diarrhea cases during the summer season including those associated with E. histolytica and G. lamblia. This study revealed that 1 in 10 causes of diarhhea among young children in the study area was likely caused by E. histolytica and G. lamblia. These findings call for community-based safe water and food safety interventions in order to reduce childhood diarrhea caused by protozoan infections in resource-poor settings.

Knowledge about the extent of the COVID-19 mortality burden is important to inform policy-making decisions. To gain greater insights into the population health impact of COVID-19 mortality, Years of Life Lost (YLL) can be estimated. We aimed to determine YLL linked to COVID-19 over the first two years (March 2020–March 2022) of the pandemic in Cyprus, by areas, and by age and sex. COVID-19 YLL was estimated by multiplying COVID-19 mortality counts by age-conditional life expectancy from the 2019 Global Burden of Disease life table. COVID-19 accounted for 16,704 YLL over the first two years of the pandemic—approximately 18.5 years lost per individual who died due to COVID-19 and 1881 YLL per 100,000 population. YLL per 100,000 was higher among males compared to females (2485 versus 1303 per 100,000) and higher among older than younger individuals. COVID-19 deaths and YLL per 100,000 were higher in high population-dense areas of Cyprus, such as Limassol. Continued evaluations of COVID-19 YLL are needed to inform on the proportionate population impact of COVID-19, over time and across areas of Cyprus.

Objectives Within the framework of the burden of disease (BoD) approach, disease and injury burden estimates attributable to risk factors are a useful guide for policy formulation and priority setting in disease prevention. Considering the important differences in methods, and their impact on burden estimates, we conducted a scoping literature review to: (1) map the BoD assessments including risk factors performed across Europe; and (2) identify the methodological choices in comparative risk assessment (CRA) and risk assessment methods. Methods We searched multiple literature databases, including grey literature websites and targeted public health agencies websites. Results A total of 113 studies were included in the synthesis and further divided into independent BoD assessments (54 studies) and studies linked to the Global Burden of Disease (59 papers). Our results showed that the methods used to perform CRA varied substantially across independent European BoD studies. While there were some methodological choices that were more common than others, we did not observe patterns in terms of country, year or risk factor. Each methodological choice can affect the comparability of estimates between and within countries and/or risk factors, since they might significantly influence the quantification of the attributable burden. From our analysis we observed that the use of CRA was less common for some types of risk factors and outcomes. These included environmental and occupational risk factors, which are more likely to use bottom-up approaches for health outcomes where disease envelopes may not be available. Conclusions Our review also highlighted misreporting, the lack of uncertainty analysis and the under-investigation of causal relationships in BoD studies. Development and use of guidelines for performing and reporting BoD studies will help understand differences, avoid misinterpretations thus improving comparability among esti

Previous efforts to estimate the burden of fatigue-related symptoms due to long COVID have a very high threshold for inclusion of cases, relative to the proposed definition from the World Health Organization. In practice this means that milder cases, that may be occurring very frequently, are not included in estimates of the burden of long COVID which will result in underestimation. A more comprehensive approach to modelling the disease burden from long COVID, in relation to fatigue, can ensure that we do not only focus on what is easiest to measure; which risks losing focus of less severe health states that may be more difficult to measure but are occurring very frequently. Our proposed approach provides a means to better understand the scale of challenge from long COVID, for consideration when preventative and mitigative action is being planned.

Exposure to chemical contaminants found in foods has been associated with various adverse health effects. Burden of disease studies are increasingly used to estimate the public health impact of such exposures. The aims of this study were to estimate the burden of disease due to dietary exposure to four chemicals in France in 2019 (lead (Pb), cadmium (Cd), methylmercury (MeHg), and inorganic arsenic (i-As)), and to develop harmonized methods that can be applied for other chemicals and countries. We used national food consumption data from the third French national food consumption survey, chemical food monitoring data from the Second French Total Diet Study (TDS), dose-response data and disability weights from scientific literature, and disease incidence and demographics from national statistics. We adopted a risk assessment approach to estimate disease burden, incidence, mortality, and Disability-Adjusted Life Years (DALYs) attributable to dietary exposure to the chemicals. In all models, we harmonized food classification and exposure assessment. We propagated uncertainty through the calculations using Monte Carlo simulation. We estimated that, among these chemicals, i-As and Pb were responsible for the highest disease burden. i-As was estimated to cause 820 DALYs, or approximately 1.25 DALYs per 100,000 inhabitants. The estimated burden of Pb was 1834 to 5936 DALYs, or 2.7 (lower bound) to 8.96 (upper bound) DALYs/100,000. The burden of MeHg (192 DALYs), and Cd (0 DALY) was substantially lower. The foods contributing most to disease burden was drinks (30 %), "other foods" (mostly composite dishes) (19 %), and fish and seafood (7 %). Interpretation of estimates needs to consider all underlying uncertainties, linked with data and knowledge gaps. The harmonized models are the first to make use of data from TDS, which are available in several other countries. Thus, they can be applied to estimate the burden and to rank food-associated chemicals at national level.

Background: Public health surveillance data do not always capture all cases, due in part to test availability and health care seeking behaviour. Our study aimed to estimate under-ascertainment multipliers for each step in the reporting chain for COVID-19 in Toronto, Canada. Design and methods: We applied stochastic modeling to estimate these proportions for the period from March 2020 (the beginning of the pandemic) through to May 23, 2020, and for three distinct windows with different laboratory testing criteria within this period. Results: For each laboratory-confirmed symptomatic case reported to Toronto Public Health during the entire period, the estimated number of COVID-19 infections in the community was 18 (5th and 95th percentile: 12, 29). The factor most associated with under-reporting was the proportion of those who sought care that received a test. Conclusions: Public health officials should use improved estimates to better understand the burden of COVID-19 and other similar infections.

Recent estimates have reiterated that non-fatal causes of disease, such as low back pain, headaches and depressive disorders, are amongst the leading causes of disability-adjusted life years (DALYs). For these causes, the contribution of years lived with disability (YLD) – put simply, ill-health – is what drives DALYs, not mortality. Being able to monitor trends in YLD closely is particularly relevant for countries that sit high on the socio-demographic spectrum of development, as it contributes more than half of all DALYs. There is a paucity of data on how the population-level occurrence of disease is distributed according to severity, and as such, the majority of global and national efforts in monitoring YLD lack the ability to differentiate changes in severity across time and location. This raises uncertainties in interpreting these findings without triangulation with other relevant data sources. Our commentary aims to bring this issue to the forefront for users of burden of disease estimates, as its impact is often easily overlooked as part of the fundamental process of generating DALY estimates. Moreover, the wider health harms of the COVID-19 pandemic have underlined the likelihood of latent and delayed demand in accessing vital health and care services that will ultimately lead to exacerbated disease severity and health outcomes. This places increased importance on attempts to be able to differentiate by both the occurrence and severity of disease.

This systematic literature review aimed to provide an overview of the characteristics and methods used in studies applying the Disability-Adjusted Life Years (DALY) concept for infectious diseases within European Union (EU)/European Economic Area (EEA)/European Free Trade Association (EFTA) countries and the United Kingdom. Electronic databases and grey literature were searched for articles reporting the assessment of DALY and its components. We considered studies in which researchers performed DALY calculations using primary epidemiological data input sources. We screened 3,053 studies of which 2,948 were excluded and 105 studies met our inclusion criteria. Of these studies, 22 were multi-country and 83 were single-country studies, of which 46 were from the Netherlands. Food- and water-borne diseases were the most frequently studied infectious diseases. Between 2015 and 2022, the number of burden of infectious disease studies was 1.6 times higher compared to that published between 2000 and 2014. Almost all studies (97%) estimated DALYs based on the incidence- and pathogen-based approach and without social weighting functions; however, there was less methodological consensus with regards to the disability weights and life tables that were applied. The number of burden of infectious disease studies undertaken across Europe has increased over time. Development and use of guidelines will promote performing burden of infectious disease studies and facilitate comparability of the results.

Salmonella remains a major cause of foodborne outbreaks in Europe despite the implementation of harmonized control programmes. Outbreak data are observed at the public health endpoint and provide a picture of the most important sources of human salmonellosis at the level of exposure. To prioritize interventions, it is important to keep abreast of the sources and trends of salmonellosis outbreaks. The objective of this study was to determine the main food sources and recent trends of Salmonella outbreaks in Europe. Salmonella outbreak data from 34 European countries in 2015-2019 were obtained from the European Food Safety Authority (EFSA). For the source attribution analysis, implicated foods were categorized according to EFSA's zoonosis catalogue classification scheme. An established probabilistic source attribution model was applied using the information on the implicated foods, overall and by region and serotype. To assess significant trends in outbreak occurrence, overall and by region and serotype, mixed-effects Poisson models were used. Overall, the most important food source of salmonellosis outbreaks was eggs (33 %, 95 % Uncertainty Interval [UI]: 31-36 %), followed by pork (7 %, 95 % UI: 6-8 %), and (general) meat products (6 %, 95 % UI: 5-8 %). While eggs were the most important food source in all regions, pork was the second most common food source in Northern and Western Europe, and (general) meat products in Eastern and Southern Europe. Outbreaks caused by S. Enteritidis (SE) and other known serotypes (other than SE and S. Typhimurium and its monophasic variant [STM]) were mostly attributed to eggs (37 %, 95 % UI: 34-41 % and 17 %, 95 % UI: 11-25 %, respectively), whereas outbreaks caused by STM were mainly attributed to pork (34 %, 95 % UI: 27-42 %). Overall, there was a significant increase in the number of outbreaks reported between 2015 and 2019, by 5 % on average per year (Incidence Rate Ratio [IRR]: 1.05, 95 % Confidence Interval [CI]: 1.01-1.09

The COVID-19 pandemic has had an enormous public health impact. In Denmark, the first case of SARS-CoV-2 infection was diagnosed on 26 Febuary and during the following year, Denmark registered over 200,000 cases and 2,600 deaths, and implemented a range of public health measures to limit spread of infections. Statens Serum Institut (SSI) is responsible for surveillance of COVID-19 in humans, including case counts, admissions and deaths. In addition, national surveys of prevalence of antibodies to SARS-CoV-2 were carried out [1][2]. These metrics have been useful to monitor the evolution of the epidemic over time, the effects of measures to reduce transmission of infection, and guide options for introducing or lifting restrictions at different stages. For assessing the health significance and severity of a disease on the society, tools that account for the overall health impact are needed. Burden of disease studies are useful to compare the public health impact of a disease across population groups, across diseases in a country, or of the same disease across countries.

Food microbiology researchers, risk assessment agencies and food business operators rely heavily on the reuse of knowledge that is available as data, models and tools. Unfortunately, such knowledge reuse remains challenging, as food safety data sets, models and tools are usually only available in platform-dependent or software-dependent formats that rarely comply to the Findability, Accessibility, Interoperability, and Reusability data principles. In recent years, the Risk Assessment Modelling and Knowledge Integration Platform (RAKIP) Initiative developed the so-called Food Safety Knowledge Exchange (FSKX) format. This development was accompanied by the creation of open-source software that facilitates the adoption of FSKX. Future work within RAKIP will focus on creating semantic interoperability in FSKX-related solutions and on the extension of the FSKX format towards other food microbiology knowledge.

Background Assessment of disability-adjusted life years (DALYs) resulting from non-communicable diseases (NCDs) requires specific calculation methods and input data. The aims of this study were to: (i) identify existing NCD burden of disease (BoD) activities in Europe; (ii) collate information on data sources for mortality and morbidity; and (iii) provide an overview of NCD-specific methods for calculating NCD DALYs. Methods NCD BoD studies were systematically searched in international electronic literature databases and in grey literature. We included all BoD studies that used the DALY metric to quantify the health impact of one or more NCDs in countries belonging to the European Region. Results A total of 163 BoD studies were retained: 96 (59%) were single-country or sub-national studies and 67 (41%) considered more than one country. Of the single-country studies, 29 (30%) consisted of secondary analyses using existing Global Burden of Disease (GBD) results. Mortality data were mainly derived (49%) from vital statistics. Morbidity data were frequently (40%) drawn from routine administrative and survey datasets, including disease registries and hospital discharge databases. The majority (60%) of national BoD studies reported mortality corrections. Multimorbidity adjustments were performed in 18% of national BoD studies. Conclusion The number of national NCD BoD assessments across Europe increased over time, driven by an increase in BoD studies that consisted of secondary data analysis of GBD study findings. Ambiguity in reporting of the use of NCD-specific BoD methods underline the need for reporting guidelines of BoD studies to enhance transparency of NCD BoD estimates across Europe.

Exposure to chemical contaminants found in foods has been associated with diverse adverse health effects. The aim of this study was to estimate the burden of disease associated with dietary exposure to four chemicals in Denmark in 2019: lead (Pb), cadmium (Cd), methylmercury (MeHg), and inorganic arsenic (i-As). We collected national food consumption and chemical food monitoring data from Danish databases, dose-response and severity data from the scientific literature, and disease incidence and population numbers from national statistics. We adopted a risk assessment approach to estimate disease burden, quantifying incidence, mortality, and Disability-Adjusted Life Years (DALYs) attributable to dietary exposure to the chemicals. In all models, we propagated uncertainty around the input parameters through the calculations using Monte Carlo simulation. We estimated that, among these chemicals, Pb and MeHg were responsible for the highest disease burden. MeHg led to the loss of nearly 600 healthy life years, or approximately 10 DALYs per 100,000 inhabitants. Dietary exposure to Pb was estimated to cause 383 to 1,261 DALYs, corresponding to 6.6 (lower bound) to 22 (upper bound) DALYs/100,000 per year. The foods contributing most to disease burden were fish (MeHg) and sweets, fruit, and bread and cereals (Pb). The burden attributed to dietary exposure to i-As (5 DALYs) and Cd (0.04 DALY) was substantially lower. Interpretation of estimates needs to consider all underlying uncertainties, linked with data and knowledge gaps. These estimates are useful supplements to traditional risk assessment to guide food safety interventions and inform dietary guidelines for different population groups.

Investigating the impact of diet on public health using risk-benefit assessment (RBA) methods that simultaneously consider both beneficial and adverse health outcomes could be useful for shaping dietary policies and guidelines. In the field of food safety and nutrition, RBA is a relatively new approach facing methodological challenges and being subject to further developments. One of the methodological aspects calling for improvement is the selection of components to be considered in the assessment, currently based mainly on non-harmonized unstandardized experts' judgment. Our aim was to develop a harmonized, transparent, and documented methodological framework for selecting nutritional, microbiological, and toxicological RBA components. The approach was developed under the Novel foods as red meat replacers-an insight using Risk-Benefit Assessment methods (NovRBA) case study, which attempted to estimate the overall health impact of replacing red meat with an edible insect species, Acheta domesticus. Starting from the compositional profiles of both food items, we created a "long list" of food components. By subsequently applying a series of predefined criteria, we proceeded from the "long" to the "short list." These criteria were established based on the occurrence and severity of health outcomes related to these components. For nutrition and microbiology, the occurrence of health outcomes was evaluated considering the presence of a component in the raw material, as well as the effect of processing on the respective component. Regarding toxicology, the presence and exposure relative to reference doses and the contribution to total exposure were considered. Severity was graded with the potential contribution to the background diet alongside bioavailability aspects (nutrition), the disability-adjusted life years per case of illness of each hazard (microbiology), and disease incidence in the population, potential fatality, and lifelong disability (toxicology). To

Background: Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies. Methods: We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021. Results: We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables. Conclusions: Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability

Salmonella remains a major cause of foodborne outbreaks in Europe despite the implementation of harmonized control programmes. Outbreak data are observed at the public health endpoint and provide a picture of the most important sources of human salmonellosis at the level of exposure. To prioritize interventions, it is important to keep abreast of the sources and trends of salmonellosis outbreaks. The objective of this study was to determine the main food sources and recent trends of Salmonella outbreaks in Europe. Salmonella outbreak data from 34 European countries in 2015–2019 were obtained from the European Food Safety Authority (EFSA). For the source attribution analysis, implicated foods were categorized according to EFSA's zoonosis catalogue classification scheme. An established probabilistic source attribution model was applied using the information on the implicated foods, overall and by region and serotype. To assess significant trends in outbreak occurrence, overall and by region and serotype, mixed-effects Poisson models were used. Overall, the most important food source of salmonellosis outbreaks was eggs (33 %, 95 % Uncertainty Interval [UI]: 31–36 %), followed by pork (7 %, 95 % UI: 6–8 %), and (general) meat products (6 %, 95 % UI: 5–8 %). While eggs were the most important food source in all regions, pork was the second most common food source in Northern and Western Europe, and (general) meat products in Eastern and Southern Europe. Outbreaks caused by S. Enteritidis (SE) and other known serotypes (other than SE and S. Typhimurium and its monophasic variant [STM]) were mostly attributed to eggs (37 %, 95 % UI: 34–41 % and 17 %, 95 % UI: 11–25 %, respectively), whereas outbreaks caused by STM were mainly attributed to pork (34 %, 95 % UI: 27–42 %). Overall, there was a significant increase in the number of outbreaks reported between 2015 and 2019, by 5 % on average per year (Incidence Rate Ratio [IRR]: 1.05, 95 % Con