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Nontyphoidal salmonellosis is the leading reported foodborne illness in Florida. Although the diversity of

Undernutrition is an underlying cause of mortality in children under five (CU5) years of age. Animal-source foods have been shown to decrease malnutrition in CU5. Livestock are important reservoirs forThis longitudinal study involves 115 infants who are followed from birth to 12 months of age and are selected randomly from 10 kebeles of Haramaya woreda, East Hararghe zone, Oromia region, Ethiopia. Questionnaire-based information is obtained on demographics, livelihoods, wealth, health, nutrition and women empowerment; animal ownership/management and diseases; and water, sanitation and hygiene. Faecal samples are collected from infants, mothers, siblings and livestock, drinking water and soil. These samples are analysed by a range of phenotypic and genotypic microbiological methods to characterise the genetic structure of theEthical approval was obtained from the University of Florida Internal Review Board (IRB201903141), the Haramaya University Institutional Health Research Ethics Committee (COHMS/1010/3796/20) and the Ethiopia National Research Ethics Review Committee (SM/14.1/1059/20). Written informed consent is obtained from all participating households. Research findings will be disseminated to stakeholders through conferences and peer-reviewed journals and through the Feed the Future Innovation Lab for Livestock Systems.

Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million-12.0 million), results in 601,000 ED visits (95% CrI 364,000-866,000), 118,000 hospitalizations (95% CrI 86,800-150,000), and 6,630 deaths (95% CrI 4,520-8,870) and incurring US $3.33 billion (95% CrI 1.37 billion-8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually.

Background Estimates by the World Health Organization indicate that over 800,000 global neonatal deaths each year are attributed to deviations from recommended best practices in infant feeding. Identifying factors promoting ideal breastfeeding practices may facilitate efforts to decrease neonatal and infant death rates and progress towards achieving the Sustainable Development Goals set for 2030. Though numerous studies have identified the benefits of breastfeeding in reducing the risk of childhood undernutrition, infection and illness, and mortality in low- and middle-income countries, no studies have explored predictors of breastfeeding practices in rural eastern Ethiopia, where undernutrition is widespread. The aim of this study is to examine predictors of infant feeding practices in Haramaya, Ethiopia, using a multi-level conceptual framework. Methods This study uses data collected from household questionnaires during the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project among 102 households in the Haramaya woreda, Eastern Hararghe Zone, Eastern Ethiopia, and investigates factors influencing breastfeeding practices: early initiation, prelacteal feeding, and untimely complementary feeding. Results Nearly half (47.9%) of infants in this study were non-exclusively breastfed (n = 96). Generalized liner mixed effects models of breastfeeding practices revealed that prelacteal feeding may be a common practice in the region (43.9%, n = 98) and characterized by gender differences (p = .03). No factors evaluated were statistically significantly predictive of early initiation and untimely complementary feeding (82% and 14%, respectively). Severely food insecure mothers had more than 72% lower odds of early breastfeeding initiation, and participants who self-reported as being illiterate had 1.53 times greater odds of untimely complementary feeding (95% CI, [0.30,7.69]) followed by male children having 1.45 greater odds of being untimely complementary fed compared to female (95% CI,[0.40,5.37]). Conclusions This study found high rates of prelacteal feeding and low prevalence of exclusive breastfeeding, with girls more likely to be exclusively breastfed. While no predictors evaluated in this multi-level framework were associated with prevalence of early initiation or complementary feeding, rates may be clinically meaningful in a region burdened by undernutrition. Findings raise questions about gendered breastfeeding norms, the under-examined role of khat consumption on infant feeding, and the complex factors that affect breastfeeding practices in this region. This information may be used to guide future research questions and inform intervention strategies.

The presence of Salmonella in poultry litter, when used as a biological soil amendment, presents a risk for the preharvest contamination of fresh produce. Poultry litter is rich in organic nitrogen, and previous studies have suggested that ammonia (NH3) in poultry litter may affect the survival of Salmonella. Salmonella enterica serovar Typhimurium was inoculated into buffer solutions to characterize the pH dependency, minimum antimicrobial concentration, and efficacy of NH3 production. In solutions with 0.4 M total ammonia nitrogen (TAN) at various pH levels (5, 7, 8, and 9), significant inactivation of Salmonella only occurred at pH 9. Salmonella was reduced by ∼8 log CFU/mL within 12 to 18 h at 0.09, 0.18, 0.26, and 0.35 M NH3. The minimum antimicrobial concentration tested was 0.04 M NH3, resulting in an ∼7 log CFU/mL reduction after 24 h. Solutions with urea (1% and 2%) and urease enzymes rapidly produced NH3, which significantly reduced Salmonella within 12 h. The urease-producing bacterium Corynebacterium urealyticum showed no antagonistic effects against Salmonella in solution. Conversely, with 1% urea added, C. urealyticum rapidly produced NH3 in solution and significantly reduced Salmonella within 12 h. Salmonella inactivation data were nonlinear and fitted to Weibull models (Weibull, Weibull with tailing effects, and double Weibull) to describe their inactivation kinetics. These results suggest that high NH3 levels in poultry litter may reduce the risk of contamination in this biological soil amendment. This study will guide future research on the influence of ammonia on the survival and persistence of Salmonella in poultry litter. IMPORTANCE Poultry litter is a widely used biological soil amendment in the production of fresh produce. However, poultry litter may contain human pathogens, such as Salmonella, which introduces the risk of preharvest produce contamination in agricultural fields. Ammonia in poultry litter, produced through bacterial degradation of urea, may be detrimental to the survival of Salmonella; however, these effects are not fully understood. This study utilized aqueous buffer solutions to demonstrate that the antimicrobial efficacy of ammonia against Salmonella is dependent on alkaline pH levels, where increasing concentrations of ammonia led to more rapid inactivation. Inactivation was also demonstrated in the presence of urea and urease or urease-producing Corynebacterium urealyticum. These findings suggest that high levels of ammonia in poultry litter may reduce the risk of contamination in biological soil amendments and will guide further studies on the survival and persistence of Salmonella in poultry litter.

Background Globally, foodborne diseases result in a significant disease burden with low- and middle-income countries disproportionately affected. Estimates of healthcare costs related to foodborne disease can aid decision makers to take action to mitigate risks and prevent illness. However, only limited data on the African continent are available, especially related to more severe sequelae. We provide estimates of direct and indirect (non)-medical costs of patients with diarrhoea, Guillain-Barré syndrome (GBS), and invasive non-typhoidal salmonellosis (iNTS) in three healthcare facilities in Gondar, Ethiopia. Methods We used healthcare data from patient records, interviews with family caregivers and 2020 healthcare resource unit costs. Descriptive statistical analysis was performed. For diarrhoea, differences in mean and median transformed costs between healthcare facilities and etiologies (Campylobacter spp., enterotoxigenic Escherichia coli, non-typhoidal Salmonella enterica) were analysed with ANOVA and chi squared tests. Contribution of healthcare facility, dehydration severity, sex, age and living area to transformed costs was identified with linear regression. Results are in 2020 USD per patient. To extrapolate to national level, 2017 national incidence estimates were used. Results Mean direct medical costs were 8.96 USD for diarrhoea (health centre 6.50 USD, specialised hospital 9.53 USD, private clinic 10.56 USD), 267.70 USD for GBS, and 47.79 USD for iNTS. Differences in costs between diarrhoea patients were mainly associated with healthcare facility. Most costs did not differ between etiologies. Total costs of a diarrhoea patient in the specialised hospital were 67 USD, or 8% of gross national income per capita. For direct medical plus transport costs of a GBS and iNTS patient in the specialised hospital, this was 33% and 8%, respectively. Of the 83.9 million USD estimated national non-typhoidal Salmonella enterica related cost, 12.2% was due to iNTS, and of 187.8 million USD related to Campylobacter spp., 0.2% was due to GBS. Conclusion Direct medical costs per patient due to GBS and iNTS were 30 respectively five times those due to diarrhoea. Costs of a patient with diarrhoea, GBS or iNTS can be a substantial part of a household’s income. More severe sequalae can add substantially to cost-of-illness of foodborne hazards causing diarrheal disease.

Background According to the World Health Organization, 600 million cases of foodborne disease occurred in 2010. To inform risk management strategies aimed at reducing this burden, attribution to specific foods is necessary. Objective We present attribution estimates for foodborne pathogens (Campylobacter spp., enterotoxigenic Escherichia coli (ETEC), Shiga-toxin producing E. coli, nontyphoidal Salmonella enterica, Cryptosporidium spp., Brucella spp., and Mycobacterium bovis) in three African countries (Burkina Faso, Ethiopia, Rwanda) to support risk assessment and cost-benefit analysis in three projects aimed at increasing safety of beef, dairy, poultry meat and vegetables in these countries. Methods We used the same methodology as the World Health Organization, i.e., Structured Expert Judgment according to Cooke’s Classical Model, using three different panels for the three countries. Experts were interviewed remotely and completed calibration questions during the interview without access to any resources. They then completed target questions after the interview, using resources as considered necessary. Expert data were validated using two objective measures, calibration score or statistical accuracy, and information score. Performance-based weights were derived from the two measures to aggregate experts’ distributions into a so-called decision maker. The analysis was made using Excalibur software, and resulting distributions were normalized using Monte Carlo simulation. Results Individual experts’ uncertainty assessments resulted in modest statistical accuracy and high information scores, suggesting overconfident assessments. Nevertheless, the optimized item-weighted decision maker was statistically accurate and informative. While there is no evidence that animal pathogenic ETEC strains are infectious to humans, a sizeable proportion of ETEC illness was attributed to animal source foods as experts considered contamination of food products by infected food handlers can occur at any step in the food chain. For all pathogens, a major share of the burden was attributed to food groups of interest. Within food groups, the highest attribution was to products consumed raw, but processed products were also considered important sources of infection. Conclusions Cooke’s Classical Model with performance-based weighting provided robust uncertainty estimates of the attribution of foodborne disease in three African countries. Attribution estimates will be combined with country-level estimates of the burden of foodborne disease to inform decision making by national authorities.

The One Health concept proposes that there is a connection between human, animal and environmental health. Plants and their health are not explicitly included. In this review, we broaden the One Health concept to include soil, plant, animal and ecosystem health. We argue that the health conditions of all organisms in an ecosystem are interconnected through the cycling of subsets of microbial communities from the environment (in particular the soil) to plants, animals and humans, and back into the environment. After an introduction on health concepts, we present examples of community stability and resilience, diversity and interconnectedness as affected by pollutants, and integrity of nutrient cycles and energy flows. Next, we explain our concept of microbial cycling in relation to ecosystem health, and end with examples of plant and animal disease outbreaks in relation to microbial community composition and diversity. We conclude that we need a better understanding of the role of interconnected microbiomes in promoting plant and animal health and possible ways to stimulate a healthy, diverse microbiome throughout human-dominated ecosystems. We suggest that it is essential to maintain ecosystem and soil health through diversification of plant communities and oligotrophication of managed ecosystems.

Non-typhoidal Salmonella enterica infections cause a high disease burden in the United States with an estimated 1.2 million illnesses annually. The state of Florida consistently has a relatively high incidence compared to other states in the United States. Nevertheless, studies regarding the epidemiology of nontyphoidal salmonellosis and its spatial and temporal patterns in Florida were rarely reported. We examined the spatial and temporal patterns of 62,947 salmonellosis cases reported to FL Health Charts between 2009 and 2018. Dominant serotypes circulating in Florida were also explored using whole genome sequencing (WGS) based serotype-prediction for 2,507 Salmonella isolates sequenced by the Florida Department of Health during 2017 and 2018. The representativeness of laboratory-sequenced isolates for reported cases was determined by regression modeling. The annual incidence rate of salmonellosis decreased from 36.0 per 100,000 population in 2009 to 27.8 per 100,000 in 2016, and gradually increased in 2017 and 2018. Increased use of culture-independent testing did not fully explain this increase. The highest incidence rate was observed in children, contributing 40.9% of total reported cases during this period. A seasonal pattern was observed with the incidence peaking in September and October, later than the national average pattern. Over these 10 years, the Northeast and Northwest regions of the state had higher reported incidence rates, while reported rates in the Southeast and South were gradually increasing over time. Serotypes were predicted based on WGS data in the EnteroBase platform. The top-five most prevalent serotypes in Florida during 2017–2018 were Enteritidis, Newport, Javiana, Sandiego and Braenderup. The highest percentage of isolates was from children under 5 years of age (41.4%), and stool (84.7%) was the major source of samples. A zero-inflated negative binomial regression model showed that the reported case number was a strong predictor for the number of lab-sequenced isolates in individual counties, and the geospatial distribution of sequenced isolates was not biased by other factors such as age group. The spatial and temporal patterns identified in this study along with the prevalence of different serotypes will be helpful for the development of efficient prevention and control strategies for salmonellosis in Florida.

High Campylobacter prevalence during early childhood has been associated with stunting and environmental enteric dysfunction (EED), especially in low resource settings. This study assessed the prevalence, diversity, abundance, and co-occurrence of Campylobacter spp. in stools from children in a rural area of eastern Ethiopia and their association with microbiome, diarrhea, and EED in children. Stool samples (n = 100) were collected from randomly selected children (age range: 360–498 days) in five kebeles in Haramaya District, Ethiopia. Diarrhea, compromised gut permeability, and gut inflammation were observed in 48, 45, and 57% of children, respectively. Campylobacter prevalence and species diversity were assessed using PCR and meta-total RNA sequencing (MeTRS). The prevalence of Campylobacter spp. in the children's stools was 50% (41–60%) by PCR and 88% (80–93.6%) by MeTRS (P < 0.01). Further, seven Campylobacter species (Campylobacter jejuni, Campylobacter upsaliensis, Campylobacter hyointestinalis, Campylobacter coli, Campylobacter sp. RM6137, uncultured Campylobacter sp., and Campylobacter sp. RM12175) were detected by MeTRS in at least 40% of children stools in high abundance (>1.76-log read per million per positive stool sample). Four clusters of Campylobacter species (5–12 species per cluster) co-occurred in the stool samples, suggesting that Campylobacter colonization of children may have occurred through multiple reservoirs or from a reservoir in which several Campylobacter species may co-inhabit. No associations between Campylobacter spp., EED, and diarrhea were detected in this cross-sectional study; however, characteristic microbiome profiles were identified based on the prevalence of Campylobacter spp., EED severity, and diarrhea. Forty-seven bacterial species were correlated with Campylobacter, and 13 of them also correlated with gut permeability, gut inflammation and/or EED severity. Forty-nine species not correlated with Campylobacter were correlated with gut permeability, gut inflammation, EED severity and/or diarrhea. This study demonstrated that (1) in addition to C. jejuni and C. coli, multiple non-thermophilic Campylobacter spp. (i.e., Campylobacter hyointestinalis, Campylobacter fetus, and Campylobacter concisus) were frequently detected in the children's stools and (2) the Campylobacter, gut permeability, gut inflammation, EED severity, and diarrhea were associated with characteristic microbiome composition. Additional spatial and longitudinal studies are needed to identify environmental reservoirs and sources of infection of children with disparate Campylobacter species and to better define their associations with EED in low-income countries.

The Florida Complaint and Outbreak Reporting System (FL-CORS) database is used by the Florida Department of Health's Food and Waterborne Disease Program as one of the tools to detect foodborne disease outbreaks (FBOs). We present a descriptive and spatial network analysis of FL-CORS data collected during 2015 to 2018. We also quantified FBOs that were investigated and confirmed because of a filed complaint and the etiological agents involved in these outbreaks. An increasing number of unique complaints filed in FL-CORS was observed during 2015 to 2018, with a sharp increase during 2017 to 2018 and a different seasonal pattern in 2018. The preferred mechanism of reporting varied by age group, with younger people more frequently filing complaints online and older people preferring reporting in person or by phone. Spatial network analysis revealed that 87% of complaints had the same county of residence and county of presumed exposure. Frequency of complaints was negatively associated with linear distance between place of residence and place of exposure at the zip code level. Counties located in North and Central Florida, as well as some coastal areas in South Florida, had higher incidence rates of complaints. Those counties tend to have a large population density, and some are popular vacation destinations. On average, 96 FBOs were reported in Florida annually, of which 60% were confirmed with successful identification of the causative agent. The 56% of the confirmed FBOs were triggered by a complaint. Throughout the years, 2.4 to 2.8 FBOs and 1.4 confirmed FBOs were identified per 100 complaints. Ciguatera toxin was the cause of 40% of all FBOs in Florida, and only 28% of outbreaks were detected through complaints. In contrast, complaints were the main source of identifying outbreaks of norovirus, nontyphoidal Salmonella enterica, and scombroid food poisoning, as well as rare outbreaks of Clostridium perfringens, Cryptosporidium spp., Shigella spp., and Vibrio vulnificus. HIGHLIGHTS

Dairy production is rapidly increasing in developing countries and making significant contributions to health, nutrition, environments, and livelihoods, with the potential for still greater contributions. However, dairy products can also contribute to human disease in many ways, with dairyborne disease likely being the most important. Health risks may be from biological, chemical, physical, or allergenic hazards present in milk and other dairy products. Lacking rigorous evidence on the full burden of foodborne and dairyborne disease in developing countries, we compiled information from different sources to improve our estimates. The most credible evidence on dairyborne disease comes from the World Health Organization initiative on the Global Burden of Foodborne Disease. This suggests that dairy products may has been responsible for 20 disability-adjusted life years per 100,000 people in 2010. This corresponds to around 4% of the global foodborne disease burden and 12% of the animal source food disease burden. Most of this burden falls on low- and middle-income countries (LMIC). However, the estimate is conservative. Weaker evidence from historical burden in high-income countries, outbreak reports from LMIC and high-income countries, and quantitative microbial risk assessment suggest that the real burden may be higher. The economic burden in terms of lost human capital is at least US$4 billion/yr in LMIC. Among the most important hazards are Mycobacterium bovis, Campylobacter spp., and non-typhoidal Salmonella enterica. The known burden of chemical hazards is lower but also more uncertain. Important chemical hazards are mycotoxins, dioxins, and heavy metals. Some interventions have been shown to have unintended and unwanted consequences, so formative research and rigorous evaluation should accompany interventions. For example, there are many documented cases in which women's control over livestock is diminished with increasing commercialization. Dairy co-operatives have had mixed success, often incurring governance and institutional challenges. More recently, there has been interest in working with the informal sector. New technologies offer new opportunities for sustainable dairy development.

Background: In recent years, ESBL/AmpC-producing Escherichia coli (ESBL/AmpC-EC) have been isolated with increasing frequency from animals, food, environmental sources and humans. With incomplete and scattered evidence, the contribution to the human carriage burden from these reservoirs remains unclear. Objectives: To quantify molecular similarities between different reservoirs as a first step towards risk attribution. Methods: Pooled data on ESBL/AmpC-EC isolates were recovered from 35 studies in the Netherlands comprising >27 000 samples, mostly obtained between 2005 and 2015. Frequency distributions of ESBL/AmpC genes from 5808 isolates and replicons of ESBL/AmpC-carrying plasmids from 812 isolates were compared across 22 reservoirs through proportional similarity indices (PSIs) and principal component analyses (PCAs). Results: Predominant ESBL/AmpC genes were identified in each reservoir. PCAs and PSIs revealed close human-animal ESBL/AmpC gene similarity between human farming communities and their animals (broilers and pigs) (PSIs from 0.8 to 0.9). Isolates from people in the general population had higher similarities to those from human clinical settings, surface and sewage water and wild birds (0.7-0.8), while similarities to livestock or food reservoirs were lower (0.3-0.6). Based on rarefaction curves, people in the general population had more diversity in ESBL/AmpC genes and plasmid replicon types than those in other reservoirs. Conclusions: Our 'One Health' approach provides an integrated evaluation of the molecular relatedness of ESBL/AmpC-EC from numerous sources. The analysis showed distinguishable ESBL/AmpC-EC transmission cycles in different hosts and failed to demonstrate a close epidemiological linkage of ESBL/AmpC genes and plasmid replicon types between livestock farms and people in the general population.

Case-control studies of outbreaks and of sporadic cases of infectious diseases may provide a biased estimate of the infection rate ratio, due to selecting controls that are not at risk of disease. We use a dynamic mathematical model to explore biases introduced in results drawn from case-control studies of enteric pathogens by waning and boosting of immunity, and by asymptomatic infections, using Campylobacter jejuni as an example. Individuals in the population are either susceptible (at risk of infection and disease), fully protected (not at risk of either) or partially protected (at risk of infection but not of disease). The force of infection is a function of the exposure frequency and the exposure dose. We show that the observed disease odds ratios are indeed strongly biased towards the null, i.e. much lower than the infection rate ratio, and furthermore even not proportional to it. The bias could theoretically be controlled by sampling controls only from the reservoir of susceptible individuals. The population at risk is in a dynamic equilibrium, and cannot be identified as those who are not and have never experienced disease. Individual-level samples to measure protective immunity would be required, complicating the design, cost and execution of case-control studies.

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.

Microbial contamination of fresh produce (fresh fruits and vegetables) poses serious public health concerns worldwide. This study was conducted as a comprehensive analysis of biological hazards in the global fresh produce chain. Data about produce-related outbreaks and illness were collected from the annual reports and databases of foodborne outbreak surveillance systems in different regions and countries from 2010 to 2015. The global patterns of and regional differences in documented outbreaks and cases were analyzed, and produce commodities and pathogens of greatest concern were identified. Data on sporadic illnesses were also collected through a comprehensive literature review of case-control studies. We found 988 produce-related outbreaks (with known agents) and 45,723 cases in all regions and countries. The numbers of produce-related outbreaks per million person-years were approximately 0.76, 0.26, 0.25, 0.13, 0.12, and 0.05 in New Zealand, Australia, the United States, the European Union, Canada, and Japan, respectively. The top three food categories and pathogens contributing to produce-related outbreaks were vegetables and nonfruits (i.e., food other than fruits; 27.0%), unspecified vegetables (12.2%), and vegetable row crops (11.7%) and norovirus (42.4%), Salmonella enterica (19.9%), and Staphylococcus aureus (7.9%), respectively. Produce consumption was identified as a protective factor, a risk factor, and either a protective or risk factor for sporadic illnesses in 11, 5, and 5 studies, respectively, among 21 case-control studies. Risks associated with produce consumption in the United States and the European Union have been linked to various factors such as irrigation water, cross-contamination, storage time and temperature abuse, infected food handlers, and unprocessed contaminated ingredients. The results of the current study indicate the complexity of produce products consumed across the globe and the difficulty in tracing illnesses back to specific food ingredients.

Background and aims: The Burden of Communicable Diseases in Europe (BCoDE) study aimed to calculate disability-adjusted life years (DALYs) for 31 selected diseases in the European Union (EU) and European Economic Area (EEA). Methods: DALYs were estimated using an incidence-based and pathogen-based approach. Incidence was estimated through assessment of data availability and quality, and a correction was applied for under-estimation. Calculation of DALYs was performed with the BCoDE software toolkit without applying time discounting and age-weighting. Results: We estimated that one in 14 inhabitants experienced an infectious disease episode for a total burden of 1.38 million DALYs (95% uncertainty interval (UI): 1.25-1.5) between 2009 and 2013; 76% of which was related to the acute phase of the infection and its short-term complications. Influenza had the highest burden (30% of the total burden), followed by tuberculosis, human immunodeficiency virus (HIV) infection/AIDS and invasive pneumococcal disease (IPD). Men had the highest burden measured in DALYs (60% of the total), adults 65 years of age and over had 24% and children less than 5 years of age had 11%. Age groupspecific burden showed that infants (less than 1 year of age) and elderly people (80 years of age and over) experienced the highest burden. Conclusions: These results provide baseline estimates for evaluating infectious disease prevention and control strategies. The study promotes an evidence-based approach to describing population health and assessing surveillance data availability and quality, and provides information for the planning and prioritisation of limited resources in infectious disease prevention and control.

Background and aims The Burden of Communicable Diseases in Europe (BCoDE) study aimed to calculate disability-adjusted life years (DALYs) for 31 selected diseases in the European Union (EU) and European Economic Area (EEA). Methods: DALYs were estimated using an incidence-based and pathogen-based approach. Incidence was estimated through assessment of data availability and quality, and a correction was applied for under-estimation. Calculation of DALYs was performed with the BCoDE software toolkit without applying time discounting and age-weighting. Results: We estimated that one in 14 inhabitants experienced an infectious disease episode for a total burden of 1.38 million DALYs (95% uncertainty interval (UI): 1.25–1.5) between 2009 and 2013; 76% of which was related to the acute phase of the infection and its short-term complications. Influenza had the highest burden (30% of the total burden), followed by tuberculosis, human immunodeficiency virus (HIV) infection/AIDS and invasive pneumococcal disease (IPD). Men had the highest burden measured in DALYs (60% of the total), adults 65 years of age and over had 24% and children less than 5 years of age had 11%. Age group-specific burden showed that infants (less than 1 year of age) and elderly people (80 years of age and over) experienced the highest burden. Conclusions: These results provide baseline estimates for evaluating infectious disease prevention and control strategies. The study promotes an evidence-based approach to describing population health and assessing surveillance data availability and quality, and provides information for the planning and prioritisation of limited resources in infectious disease prevention and control.

Background: In 2015, new disability weights (DWs) for infectious diseases were constructed based on data from four European countries. In this paper, we evaluated if country, age, sex, disease experience status, income and educational levels have an impact on these DWs. Methods: We analyzed paired comparison responses of the European DW study by participants' characteristics with separate probit regression models. To evaluate the effect of participants' characteristics, we performed correlation analyses between countries and within country by respondent characteristics and constructed seven probit regression models, including a null model and six models containing participants' characteristics. We compared these seven models using Akaike Information Criterion (AIC). Results: According to AIC, the probit model including country as covariate was the best model. We found a lower correlation of the probit coefficients between countries and income levels (range r s : 0.97-0.99, P < 0.01) than between age groups (range r s : 0.98-0.99, P < 0.01), educational level (range r s : 0.98-0.99, P < 0.01), sex ( r s = 0.99, P < 0.01) and disease status ( r s = 0.99, P < 0.01). Within country the lowest correlations of the probit coefficients were between low and high income level (range r s = 0.89-0.94, P < 0.01). Conclusions: We observed variations in health valuation across countries and within country between income levels. These observations should be further explored in a systematic way, also in non-European countries. We recommend future researches studying the effect of other characteristics of respondents on health assessment.

Fresh produce that is contaminated with viruses may lead to infection and viral gastroenteritis or hepatitis when consumed raw. It is thus important to reduce virus numbers on these foods. Prevention of virus contamination in fresh produce production and processing may be more effective than treatment, as sufficient virus removal or inactivation by post-harvest treatment requires high doses that may adversely affect food quality. To date knowledge of the contribution of various potential contamination routes is lacking. A risk assessment model was developed for human norovirus, hepatitis A virus and human adenovirus in raspberry and salad vegetable supply chains to quantify contributions of potential contamination sources to the contamination of produce at retail. These models were used to estimate public health risks. Model parameterization was based on monitoring data from European supply chains and literature data. No human pathogenic viruses were found in the soft fruit supply chains; human adenovirus (hAdV) was detected, which was additionally monitored as an indicator of fecal pollution to assess the contribution of potential contamination points. Estimated risks per serving of lettuce based on the models were 3×10(-4) (6×10(-6)-5×10(-3)) for NoV infection and 3×10(-8) (7×10(-10)-3×10(-6)) for hepatitis A jaundice. The contribution to virus contamination of hand-contact was larger as compared with the contribution of irrigation, the conveyor belt or the water used for produce rinsing. In conclusion, viral contamination in the lettuce and soft fruit supply chains occurred and estimated health risks were generally low. Nevertheless, the 97.5% upper limit for the estimated NoV contamination of lettuce suggested that infection risks up to 50% per serving might occur. Our study suggests that attention to full compliance for hand hygiene will improve fresh produce safety related to virus risks most as compared to the other examined sources, given the monitoring results. This effect will be further aided by compliance with other hygiene and water quality regulations in production and processing facilities.

To develop transparent and reproducible methods for imputing missing data on disease incidence at national-level for the year 2005.We compared several models for imputing missing country-level incidence rates for two foodborne diseases - congenital toxoplasmosis and aflatoxin-related hepatocellular carcinoma. Missing values were assumed to be missing at random. Predictor variables were selected using least absolute shrinkage and selection operator regression. We compared the predictive performance of naive extrapolation approaches and Bayesian random and mixed-effects regression models. Leave-one-out cross-validation was used to evaluate model accuracy.The predictive accuracy of the Bayesian mixed-effects models was significantly better than that of the naive extrapolation method for one of the two disease models. However, Bayesian mixed-effects models produced wider prediction intervals for both data sets.Several approaches are available for imputing missing data at national level. Strengths of a hierarchical regression approach for this type of task are the ability to derive estimates from other similar countries, transparency, computational efficiency and ease of interpretation. The inclusion of informative covariates may improve model performance, but results should be appraised carefully.وضع أساليب تتميز بالشفافية وقابلية التكرار لاحتساب البيانات المفقودة بشأن الإصابة بالمرض على الصعيد الوطني لعام 2005.قمنا بمقارنة نماذج عديدة لاحتساب معدلات الإصابة بالمرض المفقودة على صعيد البلدان لمرضين من الأمراض المنقولة بالأغذية - داء المقوسات الخلقي والسرطان الكبدي الخلوي ذو الصلة بالأفلاتوكسين. تم افتراض فقدان القيم المفقودة عشوائياً. وتم اختيار متغيرات عوامل التكهن باستخدام أدنى انكماش مطلق وارتداد عامل الانتقاء. وقمنا بمقارنة الأداء التنبؤي لأساليب الاستيفاء البسيط ونماذج الارتداد للتأثيرات المختلطة والعشوائية البايزية. وتم استخدام التحقق المتبادل باستبعاد إحدى القيم لتقدير دقة النموذج.كانت الدقة التنبؤية لنماذج التأثيرات المختلطة البايزية أفضل بشكل كبير عن تلك الخاصة بأسلوب الاستيفاء البسيط في أحد نموذجي المرض. ومع ذلك، نتج عن نماذج التأثيرات المختلطة البايزية فترات تنبؤ أوسع في كلتا فئتي البيانات.تتوفر أساليب عديدة لاحتساب البيانات المفقودة على الصعيد الوطني. وتتمثل نقاط قوة نموذج الارتداد الهرمي لهذا النوع من النهج في قدرته على استخلاص التقديرات من البلدان المشابهة الأخرى والشفافية والكفاءة الحاسوبية وسهولة التفسير. ويمكن أن يحسن إدراج المتغيرات المصاحبة الثرية بالمعلومات من أداء النموذج، غير أنه ينبغي تقييم النتائج بدقة.开发2005年国家级疾病发病率缺失数据透明和可重复的填补方法。.我们比较填补两种食源性疾病的缺失国家级发病率的几种模型：先天性弓形体病和黄曲霉毒素相关的肝细胞癌。假定缺失值是随机缺失。使用最小一乘收缩和选择算子（LASSO）回归来选择预测变量。我们比较自然推论方法和贝叶斯随机和混合效应回归模型的预测性能。使用留一交叉验证来评估模型的准确性。.在两种疾病模型的其中一种当中，贝叶斯混合效应模型的预测精度明显优于自然推论方法。然而，贝叶斯混合效应模型对两个数据集生成的预测区间都更宽。.国家层面缺失数据有若干种填补方法。此类任务的分层回归方法的优势在于从其他类似国家得出估算值的能力、透明性、计算效率和解释上的方便。增加信息性的协变量可以改善模型性能，但应对其结果进行仔细地评估。.Développer des méthodes transparentes et reproductibles pour imputer les données manquantes sur l'incidence d'une maladie au niveau national pour l'année 2005.Nous avons comparé plusieurs modèles pour imputer les taux d'incidence manquants au niveau national pour deux maladies d'origine alimentaire: la toxoplasmose congénitale et le carcinome hépatocellulaire lié à l'aflatoxine. Les valeurs manquantes sont supposées être manquantes au hasard. Les variables prédictives ont été sélectionnées en utilisant la régression LASSO (La précision prédictive des modèles des effets mixtes bayésiens était significativement meilleure que celle de la méthode d'extrapolation naïve pour l'un des deux modèles de maladie. Cependant, les modèles d'effets mixtes bayésiens ont produit des intervalles de prédiction plus larges pour les deux ensembles de données.Plusieurs approches sont disponibles pour imputer les données manquantes au niveau national. Les forces d'une approche de régression hiérarchique de ce type de tâche sont la capacité de dériver des estimations à partir d'autres pays similaires, la transparence, l'efficacité des calculs et la facilité d'interprétation. L'inclusion de covariables informatives peut améliorer la performance du modèle mais les résultats doivent être évalués avec prudence.Разработать прозрачные и воспроизводимые методы ввода отсутствующих данных о распространенности заболевания на национальном уровне за 2005 год.Производилось сравнение нескольких моделей ввода отсутствующих данных о частоте случаев заболевания на национальном уровне для двух заболеваний пищевого происхождения: врожденный токсоплазмоз и афлатоксин-зависимая гепатоклеточная карцинома. Отсутствующие значения были расценены как не имеющие определенной закономерности. Прогностические переменные были выбраны с использованием наименьшего абсолютного значения естественной убыли и регрессии оператора выбора. Было произведено сравнение прогностической эффективности методов первичной экстраполяции и байесовских регрессионных моделей со случайными и смешанными эффектами. Для оценки точности моделей использовалась перекрестная проверка с исключением.Прогностическая точность байесовских моделей со смешанными эффектами была существенно выше, чем при использовании метода первичной экстраполяции для одной из двух моделей заболевания. Тем не менее, байесовские модели со смешанными эффектами позволили получить более широкие прогностические интервалы для обеих совокупностей данных.Доступно несколько подходов к вводу отсутствующих данных на национальном уровне. Сильными сторонами подхода к решению задач данного типа с использованием метода многоуровневой регрессии являются возможность выведения приблизительных значений на основе данных для других схожих стран, прозрачность, эффективность вычислений и легкость интерпретации. Включение информативных ковариат может повысить эффективность модели, но результаты должны подвергаться тщательной оценке.Desarrollar métodos transparentes y reproducibles de imputación de datos ausentes sobre la incidencia de la morbilidad a nivel nacional para el año 2005.Se compararon varios modelos de imputación de las tasas ausentes de incidencia a nivel nacional para dos enfermedades transmitidas por los alimentos, la toxoplasmosis congénita y el carcinoma hepatocelular relacionado con la aflatoxina. Se consideró que los valores ausentes faltaban al azar. Las variables de predicción se seleccionaron por medio de la contracción absoluta mínima y la regresión del operador de la selección. Se comparó el rendimiento predictivo de los enfoques de extrapolación ingenua y los modelos bayesianos de regresión al azar y de efectos mixtos, y se empleó una validación cruzada dejando uno fuera para evaluar la exactitud del modelo.La exactitud predictiva de los modelos bayesianos de efectos mixtos fue significativamente mejor que la del método de extrapolación ingenua para uno de los dos modelos de enfermedad. Sin embargo, los modelos bayesianos de efectos mixtos generaron intervalos de predicción más amplios para ambos conjuntos de datos.Son numerosos los enfoques disponibles para la imputación de datos ausentes a nivel nacional. Los puntos fuertes de un enfoque de regresión jerárquica para este tipo de tareas son la capacidad de obtener estimaciones de otros países similares, la transparencia, la eficiencia informática y la facilidad de interpretación. La inclusión de covariables informativas puede mejorar el rendimiento del modelo, aunque se deben evaluar atentamente los resultados.

Outbreaks of human illness caused by enteric pathogens such as Salmonella are increasingly linked to the consumption of fruits and vegetables. Knowledge on the factors affecting Salmonella proliferation on fresh produce therefore becomes increasingly important to safeguard public health. Previous experiments showed a limited impact of pre-harvest production practices on Salmonella proliferation on tomatoes, but suggested a significant effect of harvest time. We explored the data from two previously published and one unpublished experiment using regression trees, which allowed overcoming the interpretational difficulties of classical statistical models with higher order interactions. We assessed the effect of harvest time by explicitly modeling the climatic conditions at harvest time and by performing confirmatory laboratory experiments. Across all datasets, regression trees confirmed the dominant effect of harvest time on Salmonella proliferation, with humidity-related factors emerging as the most important underlying climatic factors. High relative humidity the week prior to harvest was consistently associated with lower Salmonella proliferation. A controlled lab experiment confirmed that tomatoes containing their native epimicrobiota supported significantly lower Salmonella proliferation when incubated at higher humidity prior to inoculation. The complex interactions between environmental conditions and the native microbiota of the tomato crop remain to be fully understood.

Salmonellosis, campylobacteriosis and listeriosis are food-borne diseases. We estimated and forecasted the number of cases of these three diseases in Belgium from 2012 to 2020, and calculated the corresponding number of disability-adjusted life years (DALYs). The salmonellosis time series was fitted with a Bai and Perron two-breakpoint model, while a dynamic linear model was used for campylobacteriosis and a Poisson autoregressive model for listeriosis. The average monthly number of cases of salmonellosis was 264 (standard deviation (SD): 86) in 2012 and predicted to be 212 (SD: 87) in 2020; campylobacteriosis case numbers were 633 (SD: 81) and 1,081 (SD: 311); listeriosis case numbers were 5 (SD: 2) in 2012 and 6 (SD: 3) in 2014. After applying correction factors, the estimated DALYs for salmonellosis were 102 (95% uncertainty interval (UI): 8–376) in 2012 and predicted to be 82 (95% UI: 6–310) in 2020; campylobacteriosis DALYs were 1,019 (95% UI: 137–3,181) and 1,736 (95% UI: 178–5,874); listeriosis DALYs were 208 (95% UI: 192–226) in 2012 and 252 (95% UI: 200–307) in 2014. New actions are needed to reduce the risk of food-borne infection with Campylobacter spp. because campylobacteriosis incidence may almost double through 2020.

Summary Background Listeriosis, caused by Listeria monocytogenes , is an important foodborne disease that can be difficult to control and commonly results in severe clinical outcomes. We aimed to provide the first estimates of global numbers of illnesses, deaths, and disability-adjusted life-years (DALYs) due to listeriosis, by synthesising information and knowledge through a systematic review. Methods We retrieved data on listeriosis through a systematic review of peer-reviewed and grey literature (published in 1990–2012). We excluded incidence data from before 1990 from the analysis. We reviewed national surveillance data where available. We did a multilevel meta-analysis to impute missing country-specific listeriosis incidence rates. We used a meta-regression to calculate the proportions of health states, and a Monte Carlo simulation to generate DALYs by WHO subregion. Findings We screened 11 722 references and identified 87 eligible studies containing listeriosis data for inclusion in the meta-analyses. We estimated that, in 2010, listeriosis resulted in 23 150 illnesses (95% credible interval 6061–91 247), 5463 deaths (1401–21 497), and 172 823 DALYs (44 079–676 465). The proportion of perinatal cases was 20·7% (SD 1·7). Interpretation Our quantification of the global burden of listeriosis will enable international prioritisation exercises. The number of DALYs due to listeriosis was lower than those due to congenital toxoplasmosis but accords with those due to echinococcosis. Urgent efforts are needed to fill the missing data in developing countries. We were unable to identify incidence data for the AFRO, EMRO, and SEARO WHO regions. Funding WHO Foodborne Diseases Epidemiology Reference Group and the Universite catholique de Louvain.

Infection with Toxoplasma gondii is acquired through consumption of undercooked infected meat, or by uptake of cat-shed oocysts. Although congenital toxoplasmosis is generally considered to contribute most to the disease burden of T. gondii, ocular disease from acquired infection was recently shown to add substantially to the burden. In addition, toxoplasmosis in immune-compromised individuals usually results from reactivation of an infection acquired earlier in life. Nevertheless, prevention of toxoplasmosis commonly targets mainly pregnant women. We summarize current prevention strategies of congenital toxoplasmosis and evaluate options to improve protection of the general population (including pregnant women). To protect the general population, freezing of meat destined for raw or undercooked consumption is the most readily applicable option, especially when limited to meat from animals originating from nonbiosecure husbandry systems. In the long term, more health benefits are expected from cat vaccination; therefore, development of a cat vaccine and evaluation of its implementation is a research priority.

Illness and death from diseases caused by contaminated food are a constant threat to public health and a significant impediment to socio-economic development worldwide. To measure the global and regional burden of foodborne disease (FBD), the World Health Organization (WHO) established the Foodborne Disease Burden Epidemiology Reference Group (FERG), which here reports their first estimates of the incidence, mortality, and disease burden due to 31 foodborne hazards. We find that the global burden of FBD is comparable to those of the major infectious diseases, HIV/AIDS, malaria and tuberculosis. The most frequent causes of foodborne illness were diarrheal disease agents, particularly norovirus and Campylobacter spp. Diarrheal disease agents, especially non-typhoidal Salmonella enterica, were also responsible for the majority of deaths due to FBD. Other major causes of FBD deaths were Salmonella Typhi, Taenia solium and hepatitis A virus. The global burden of FBD caused by the 31 hazards in 2010 was 33 million Disability Adjusted Life Years (DALYs); children under five years old bore 40% of this burden. The 14 subregions, defined on the basis of child and adult mortality, had considerably different burdens of FBD, with the greatest falling on the subregions in Africa, followed by the subregions in South-East Asia and the Eastern Mediterranean D subregion. Some hazards, such as non-typhoidal S. enterica, were important causes of FBD in all regions of the world, whereas others, such as certain parasitic helminths, were highly localised. Thus, the burden of FBD is borne particularly by children under five years old–although they represent only 9% of the global population–and people living in low-income regions of the world. These estimates are conservative, i.e., underestimates rather than overestimates; further studies are needed to address the data gaps and limitations of the study. Nevertheless, all stakeholders can contribute to improvements in food safety throughout the food chain by incorporating these estimates into policy development at national and international levels., An overview of foodborne diseases worldwide; part of the World Health Organization’s investigation into the incidence, mortality, and disease burden of foodborne hazards.

Burden of disease (BoD) studies aim to identify the public health impact of different health problems and risk factors. To assess BoD, detailed knowledge is needed on epidemiology, disability and mortality in the population under study. This is particularly challenging for foodborne disease, because of the multitude of causative agents and their health effects. The purpose of this study is to systematically review the methodology of foodborne BoD studies. Three key questions were addressed: 1) which data sources and approaches were used to assess mortality, morbidity and disability?, 2) which methodological choices were made to calculate Disability Adjusted Life Years (DALY), and 3) were uncertainty analyses performed and if so, how? Studies (1990-June 2012) in international peer-reviewed journals and grey literature were identified with main inclusion criteria being that the study assessed disability adjusted life years related to foodborne disease. Twenty-four studies met our inclusion criteria. To assess incidence or prevalence of foodborne disease in the population, four approaches could be distinguished, each using a different data source as a starting point, namely 1) laboratory-confirmed cases, 2) cohort or cross-sectional data, 3) syndrome surveillance data and 4) exposure data. Considerable variation existed in BoD methodology (e.g. disability weights, discounting, age-weighting). Almost all studies analyzed the effect of uncertainty as a result of possible imprecision in the parameter values. Awareness of epidemiological and methodological rigor between foodborne BoD studies using the DALY approach is a critical priority for advancing burden of disease studies. Harmonization of methodology that is used and of modeling techniques and high quality data can enlarge the detection of real variation in DALY outcomes between pathogens, between populations or over time. This harmonization can be achieved by identifying substantial data gaps and uncertainty and establish which sequelae of foodborne disease agents should be included in BoD calculations. (C) 2013 Elsevier B.V. All rights reserved.

A demographic shift towards a larger proportion of elderly in the Dutch population in the coming decades might change foodborne disease incidence and mortality. In the current study we focused on the age-specific changes in the occurrence of foodborne pathogens by combining age-specific demographic forecasts for 10-year periods between 2020 and 2060 with current age-specific infection probabilities for Campylobacter spp., non-typhoidal Salmonella, hepatitis A virus, acquired Toxoplasma gondii and Listeria monocytogenes. Disease incidence rates for the former three pathogens were estimated to change marginally, because increases and decreases in specific age groups cancelled out over all ages. Estimated incidence of reported cases per 100,000 for 2060 mounted to 12 (Salmonella), 51 (Campylobacter), 1.1 (hepatitis A virus) and 2.1 (Toxoplasma). For L. monocytogenes, incidence increased by 45% from 0.41 per 100,000 in 2011 to 0.60 per 100,000. Estimated mortality rates increased two-fold for Salmonella and Campylobacter to 0.5 and 0.7 per 100,000, and increased by 25% for Listeria from 0.06 to 0.08. This straightforward scoping effort does not suggest major changes in incidence and mortality for these food borne pathogens based on changes in de population age-structure as independent factor. Other factors, such as changes in health care systems, social clustering and food processing and preparation, could not be included in the estimates.

SUMMARYNoroviruses are an important cause of acute gastroenteritis in humans. We incorporated new insights gained over the past decade in an updated estimate of the disease burden of (foodborne) norovirus illness in The Netherlands in 2009. The disease outcomes – non-consulting cases, visiting a general practitioner, hospitalization and mortality – and the foodborne proportion were derived from cohort studies, surveillance data and literature. Age-specific incidence estimates were applied to the population age distribution in The Netherlands in 2009. The general population incidence was 3800/100 000 (95% CI 2670–5460), including 0·4 fatal cases/100 000, resulting in 1622/100 000 (95% CI 966–2650) disability-adjusted life-years in a population of 16·5 million. The updated burden of norovirus is over twofold higher than previously estimated, due in particular to the new insights in case-fatality ratios. Results suggest that the burden of norovirus institutional outbreaks is relatively small compared to the burden of community-acquired norovirus infections.

BACKGROUND: The Foodborne Disease Burden Epidemiology Reference Group (FERG) was established in 2007 by the World Health Organization (WHO) to estimate the global burden of foodborne diseases (FBDs). This estimation is complicated because most of the hazards causing FBD are not transmitted solely by food; most have several potential exposure routes consisting of transmission from animals, by humans, and via environmental routes including water. This paper describes an expert elicitation study conducted by the FERG Source Attribution Task Force to estimate the relative contribution of food to the global burden of diseases commonly transmitted through the consumption of food. METHODS AND FINDINGS: We applied structured expert judgment using Cooke's Classical Model to obtain estimates for 14 subregions for the relative contributions of different transmission pathways for eleven diarrheal diseases, seven other infectious diseases and one chemical (lead). Experts were identified through international networks followed by social network sampling. Final selection of experts was based on their experience including international working experience. Enrolled experts were scored on their ability to judge uncertainty accurately and informatively using a series of subject-matter specific 'seed' questions whose answers are unknown to the experts at the time they are interviewed. Trained facilitators elicited the 5th, and 50th and 95th percentile responses to seed questions through telephone interviews. Cooke's Classical Model uses responses to the seed questions to weigh and aggregate expert responses. After this interview, the experts were asked to provide 5th, 50th, and 95th percentile estimates for the 'target' questions regarding disease transmission routes. A total of 72 experts were enrolled in the study. Ten panels were global, meaning that the experts should provide estimates for all 14 subregions, whereas the nine panels were subregional, with experts providing estimates for one or more subregions, depending on their experience in the region. The size of the 19 hazard-specific panels ranged from 6 to 15 persons with several experts serving on more than one panel. Pathogens with animal reservoirs (e.g. non-typhoidal Salmonella spp. and Toxoplasma gondii) were in general assessed by the experts to have a higher proportion of illnesses attributable to food than pathogens with mainly a human reservoir, where human-to-human transmission (e.g. Shigella spp. and Norovirus) or waterborne transmission (e.g. Salmonella Typhi and Vibrio cholerae) were judged to dominate. For many pathogens, the foodborne route was assessed relatively more important in developed subregions than in developing subregions. The main exposure routes for lead varied across subregions, with the foodborne route being assessed most important only in two subregions of the European region. CONCLUSIONS: For the first time, we present worldwide estimates of the proportion of specific diseases attributable to food and other major transmission routes. These findings are essential for global burden of FBD estimates. While gaps exist, we believe the estimates presented here are the best current source of guidance to support decision makers when allocating resources for control and intervention, and for future research initiatives.

Background Listeriosis is a rare disease caused by the bacterium Listeria monocytogenes and mainly affects at risk people. Listeriosis can lead to sepsis, central nervous system (CNS) infections and death. The objectives of this study were to describe and quantify comorbidities and neurological sequelae underlying non-perinatal listeriosis cases and to describe the factors associated with death and CNS infections in non-perinatal listeriosis. Methods We retrospectively collected clinical data through computerized, paper or microfilmed medical records in two Belgian university hospitals. Logistic regression models and likelihood ratio tests allowed identifying factors associated with death and CNS infections. Results Sixty-four cases of non-perinatal listeriosis were included in the clinical case series and 84 % were affected by at least one comorbid condition. The main comorbidities were cancer, renal and severe cardio-vascular diseases. Twenty-nine patients (45 %) suffered from a CNS infection and 14 patients (22 %) died during hospitalization, among whom six (43 %) had a CNS involvement. Among surviving patients, eleven suffered from neurological sequelae (22 %) at hospital discharge; all had CNS infection. Five of these patients (45 %) still suffered of their neurological sequelae after a median follow-up of one year (range: 0.08–19). The factor associated with death during the hospitalization was the presence of a severe cardiovascular disease (OR = 4.72, p = 0.015). Two factors inversely related with CNS infections were antibiotic monotherapy (OR = 0.28, p = 0.04) and the presence of renal disease (OR = 0.18, p = 0.02). Conclusions In a public health context these results could be a starting point for future burden of listeriosis studies taking into account comorbidity. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1602-3) contains supplementary material, which is available to authorized users.

SUMMARYWe estimated the true incidence of campylobacteriosis and salmonellosis in the European Union (EU) in 2009. The estimate was based on disease risks of returning Swedish travellers, averaged over the years 2005–2009, and anchored to a Dutch population-based study on incidence and aetiology of gastroenteritis. For the 27 EU member states the incidence of campylobacteriosis was about 9·2 (95% CI 2·8–23) million cases, while the incidence of salmonellosis was 6·2 (95% CI 1·0–19) million cases. Only 1/47 (95% CI 14–117) cases of campylobacteriosis and one 1/58 (95% CI 9–172) cases of salmonellosis were reported in the EU. The incidence rate of campylobacteriosis in EU member states varied between 30 and 13 500/100 000 population and was significantly correlated with the prevalence of Campylobacter spp. in broiler chickens. The incidence rate of salmonellosis in EU member states varied between 16 and 11 800/100 000 population and was significantly correlated with the prevalence of Salmonella Enteritidis in laying hens.

While previous behavioural research suggests that attitudes, for example towards elderly people, may be activated automatically, this type of research does not provide information about the detailed time-course of such processing in the brain. We investigated the impact of age related attitude information in a Go/NoGo association task that paired photographs of elderly or young faces with positive or negative words. Event related brain potentials showed an N200 (NoGo) component, which appeared earlier in runs which required similar responses for congruent stimulus pairings (e.g. respond to pictures of elderly faces or negative words) than for incongruent pairings (e.g. respond to elderly faces or positive words). As information processing leading to a certain attitude must precede differential brain activity according to the congruence of the paired words and faces, we show that this type of information is activated almost immediately following the structural encoding of the face, between 170 and 230 ms after onset of the face.

Infections with Shiga toxin producing Escherichia coli O157 (STEC O157) are associated with hemorrhagic colitis, hemolytic uremic syndrome (HUS), and end-stage renal disease (ESRD). In the present study, we extend previous estimates of the burden of disease associated with STEC O157 with estimates of the associated cost of illness in The Netherlands. A second-order stochastic simulation model was used to calculate disease burden as disability-adjusted life years (DALYs) and cost of illness (including direct health care costs and indirect non health care costs). Future burden and costs are presented undiscounted and discounted at annual percentages of 1.5 and 4%, respectively. Annually, approximately 2.100 persons per year experience symptoms of gastroenteritis, leading to 22 cases of HUS and 3 cases of ESRD. The disease burden at the population level was estimated at 133 DALYs (87 DALYs discounted) per year. Total annual undiscounted and discounted costs of illness due to STEC O157 infection for the Dutch society were estimated at sic9.1 million and sic4.5 million, respectively. Average lifetime undiscounted and discounted costs per case were both sic126 for diarrheal illness, both sic25,713 for HUS, and sic2.76 million and sic1.22 million, respectively, for ESRD. The undiscounted and discounted costs per case of diarrheal disease including sequelae were sic4,132 and sic2,131, respectively. Compared with other foodbome pathogens, STEC O157 infections result in relatively low burden and low annual costs at the societal level, but the burden and costs per case are high.

The discovery, synthesis and structure-activity relationship (SAR) of a novel series of cannabinoid 1 (CB(1)) and cannabinoid 2 (CB(2)) receptor ligands are reported. Based on the aminoalkylindole class of cannabinoid receptor agonists, a biphenyl moiety was introduced as novel lipophilic indole 3-acyl substituent in 11-16. Furthermore, the 3-carbonyl tether was replaced with a carboxamide linker in 17-20 and the azaindole (pyrrolopyridine) nucleus was designed as indole bioisostere with improved physicochemical properties in 21-25. Through these SAR efforts, several high affinity CB(1)/CB(2) dual cannabinoid receptor ligands were identified. Indole-3-carboxamide 17 displayed single-digit nanomolar affinity and ~80 fold selectivity for CB(1) over the CB(2) receptor. The azaindoles displayed substantially improved physicochemical properties (lipophilicity; aqueous solubility). Azaindole 21 elicited potent cannabinoid activity. Cannabinoid receptor agonists 17 and 21 potently modulated excitatory synaptic transmission in an acute rat brain slice model of cannabinoid receptor-modulated neurotransmission.

Background Psychological consequences such as posttraumatic stress disorder (PTSD) are currently neglected in burden-of-injury calculations. Aim To assess the disease burden of PTSD due to unintentional injury and compare this health loss with physical injury consequences. Methods From literature sources, the prevalence of PTSD at four follow-up periods (< 3 months, 3-6 months, 7-12 months and >12 months) was estimated. The uncertainty of the estimated PTSD prevalence was modelled by a Bayesian approach. The prevalence rates were then linked to national data on unintentional injury, disability weights and duration to estimate the incidence and disability-adjusted life years (DALY) resulting from PTSD in addition to physical injury consequences. Results The data suggest that PTSD prevalence among injury victims decreases over time. The average PTSD prevalence at

The Key Events Dose-Response Framework (KEDRF) is an analytical approach that facilitates the use of currently available data to gain insight regarding dose-response relationships. The use of the KEDRF also helps identify critical knowledge gaps that once filled, will reduce reliance on assumptions. The present study considers how the KEDRF might be applied to pathogenic microorganisms, using fetal listeriosis resulting from maternal ingestion of food contaminated with L. monocytogenes as an initial example. Major biological events along the pathway between food ingestion and the endpoint of concern are systematically considered with regard to dose (i.e., number of organisms), pathogen factors (e.g., virulence), and protective host mechanisms (e.g., immune response or other homeostatic mechanisms). It is concluded that the KEDRF provides a useful structure for systematically evaluating the complex array of host and pathogen factors that influence the dose-response relationship. In particular, the KEDRF supports efforts to specify and quantify the sources of variability, a prerequisite to strengthening the scientific basis for food safety decision making.

We develop a model for bacterial cross-contamination during food preparation in the domestic kitchen and apply this to the case of Campylobacter-contaminated chicken breast. Building blocks of the model are the routines performed during food preparation, with their associated probabilities of bacterial transfer between food items and kitchen utensils. The model is used in a quantitative microbiological risk assessment (QMRA) of Campylobacter in the Netherlands. Using parameter values from the literature and performing elementary sensitivity analyses, we show that cross-contamination can contribute significantly to the risk of Campylobacter infection and find that cleaning frequency of kitchen utensils and thoroughness of rinsing of raw food items after preparation has more impact on cross-contamination than previously emphasized. Furthermore, we argue that especially more behavioral data on hygiene during food preparation is needed for a comprehensive Campylobacter risk assessment.

Although the outcomes of toxoplasmosis have been well documented, an integrated estimate of the impact of this infection on the health status of the population is not available. "Disability-adjusted life years" are the sum of years of life lost and years lived with disability, weighted for the severity of the illness. The estimated disease burden of congenital toxoplasmosis in The Netherlands is 620 (range, 220-1900) disability-adjusted life years per year, which is similar to that for salmonellosis and is mainly caused by fetal loss and chorioretinitis. However, there is considerable uncertainty in this estimate. Scenario analysis indicates that the true burden may be underestimated. In other countries, the disease burden is expected to vary with the incidence of congenital infection, but it may also depend on the health care system. In countries that actively screen for toxoplasmosis, such as France, there may be a lower burden of morbidity but a higher burden of mortality.

Campylobacter bacteria are an important cause of foodborne infections. We estimated the potential costs and benefits of a large number of possible interventions to decrease human exposure to Campylobacter by consumption of chicken meat, which accounts for 20-40% of all cases of human campylobacteriosis in the Netherlands. For this purpose, a farm-to-fork risk assessment model was combined with economic analysis and epidemiological data. Reduction of contamination at broiler farms could be efficient in theory. However, it is unclear which hygienic measures need to be taken and the costs can be very high. The experimental treatment of colonized broiler flocks with bacteriophages has proven to be effective and could also be cost efficient, if confirmed in practice. Since a major decrease of infections at the broiler farm is not expected in the short term, additional measures in the processing plant were also considered. At this moment, guaranteed Campylobacter-free chicken meat at the retail level is not realistic. The most promising interventions in the processing plant are limiting fecal leakage during processing and separation of contaminated and noncontaminated flocks (scheduling), followed by decontamination of the contaminated flock. New (faster and more sensitive) test methods to detect Campylobacter colonization in broilers flocks are a prerequisite for successful scheduling scenarios. Other methods to decrease the contamination of meat of colonized flocks such as freezing and heat treatment are more expensive and/or less effective than chemical decontamination.

BACKGROUND: Lyme borreliosis (LB) is the most commonly reported tick-borne infection in Europe and North America. In the last 15 years a 3-fold increase was observed in general practitioner consultations for LB in the Netherlands. To support prioritization of prevention and control efforts for LB, we estimated its burden expressed in Disability-Adjusted Life Years (DALYs). METHODS: We used available incidence estimates for three LB outcomes: (i) erythema migrans (EM), (ii) disseminated LB and (iii) Lyme-related persisting symptoms. To generate DALYs, disability weights and duration per outcome were derived using a patient questionnaire including health-related quality of life as measured by the EQ-5D. RESULTS: We estimated the total LB burden for the Netherlands in 2010 at 10.55 DALYs per 100 000 population (95% CI: 8.80-12.43); i.e. 0.60 DALYs for EM, 0.86 DALYs for disseminated LB and 9.09 DALYs for Lyme-related persisting symptoms. Per patient this was 0.005 DALYs for EM, 0.113 for disseminated LB and 1.661 DALYs for a patient with Lyme-related persisting symptoms. In a sensitivity analysis the total LB burden ranged from 7.58 to 16.93 DALYs per 100 000 population. CONCLUSIONS: LB causes a substantial disease burden in the Netherlands. The vast majority of this burden is caused by patients with Lyme-related persisting symptoms. EM and disseminated Lyme have a more modest impact. Further research should focus on the mechanisms that trigger development of these persisting symptoms that patients and their physicians attribute to LB.

Foodborne diseases are important worldwide, resulting in considerable morbidity and mortality. To our knowledge, we present the first global and regional estimates of the disease burden of the most important foodborne bacterial, protozoal, and viral diseases.We synthesized data on the number of foodborne illnesses, sequelae, deaths, and Disability Adjusted Life Years (DALYs), for all diseases with sufficient data to support global and regional estimates, by age and region. The data sources included varied by pathogen and included systematic reviews, cohort studies, surveillance studies and other burden of disease assessments. We sought relevant data circa 2010, and included sources from 1990-2012. The number of studies per pathogen ranged from as few as 5 studies for bacterial intoxications through to 494 studies for diarrheal pathogens. To estimate mortality for Mycobacterium bovis infections and morbidity and mortality for invasive non-typhoidal Salmonella enterica infections, we excluded cases attributed to HIV infection. We excluded stillbirths in our estimates. We estimate that the 22 diseases included in our study resulted in two billion (95% uncertainty interval [UI] 1.5-2.9 billion) cases, over one million (95% UI 0.89-1.4 million) deaths, and 78.7 million (95% UI 65.0-97.7 million) DALYs in 2010. To estimate the burden due to contaminated food, we then applied proportions of infections that were estimated to be foodborne from a global expert elicitation. Waterborne transmission of disease was not included. We estimate that 29% (95% UI 23-36%) of cases caused by diseases in our study, or 582 million (95% UI 401-922 million), were transmitted by contaminated food, resulting in 25.2 million (95% UI 17.5-37.0 million) DALYs. Norovirus was the leading cause of foodborne illness causing 125 million (95% UI 70-251 million) cases, while Campylobacter spp. caused 96 million (95% UI 52-177 million) foodborne illnesses. Of all foodborne diseases, diarrheal and invasive infections due to non-typhoidal S. enterica infections resulted in the highest burden, causing 4.07 million (95% UI 2.49-6.27 million) DALYs. Regionally, DALYs per 100,000 population were highest in the African region followed by the South East Asian region. Considerable burden of foodborne disease is borne by children less than five years of age. Major limitations of our study include data gaps, particularly in middle- and high-mortality countries, and uncertainty around the proportion of diseases that were foodborne.Foodborne diseases result in a large disease burden, particularly in children. Although it is known that diarrheal diseases are a major burden in children, we have demonstrated for the first time the importance of contaminated food as a cause. There is a need to focus food safety interventions on preventing foodborne diseases, particularly in low- and middle-income settings.

Background Atmospheric dispersion models (ADMs) may help to assess human exposure to airborne pathogens. However, there is as yet limited quantified evidence that modelled concentrations are indeed associated to observed human incidence. Methods We correlated human Q fever (caused by the bacterium Coxiella burnetii) incidence data in the Netherlands to modelled concentrations from three spatial exposure models: 1) a NULL model with a uniform concentration distribution, 2) a DISTANCE model with concentrations proportional to the distance between the source and residential addresses of patients, and 3) concentrations modelled by an ADM using three simple emission profiles. We used a generalized linear model to correlate the observed incidences to modelled concentrations and validated it using cross-validation. Results ADM concentrations generally correlated the best to the incidence data. The DISTANCE model always performed significantly better than the NULL model. ADM concentrations based on wind speeds exceeding threshold values of 0 and 2 m/s performed better than those based on 4 or 6 m/s. This might indicate additional exposure to bacteria originating from a contaminated environment. Conclusions By adding meteorological information the correlation between modelled concentration and observed incidence improved, despite using three simple emission profiles. Although additional information is needed – especially regarding emission data - these results provide a basis for the use of ADMs to predict and to visualize the spread of airborne pathogens during livestock, industry and even bio-terroristic related outbreaks or releases to a surrounding human population. Electronic supplementary material The online version of this article (doi:10.1186/s12942-015-0003-y) contains supplementary material, which is available to authorized users.

Background: The Foodborne Disease Burden Epidemiology Reference Group (FERG) was established in 2007 by the World Health Organization to estimate the global burden of foodborne diseases (FBDs). This paper describes the methodological framework developed by FERG's Computational Task Force to transform epidemiological information into FBD burden estimates. Methods and Findings: The global and regional burden of 31 FBDs was quantified, along with limited estimates for 5 other FBDs, using Disability-Adjusted Life Years in a hazard- and incidence-based approach. To accomplish this task, the following workflow was defined: outline of disease models and collection of epidemiological data; design and completion of a database template; development of an imputation model; identification of disability weights; probabilistic burden assessment; and estimating the proportion of the disease burden by each hazard that is attributable to exposure by food (i.e., source attribution). All computations were performed in R and the different functions were compiled in the R package 'FERG'. Traceability and transparency were ensured by sharing results and methods in an interactive way with all FERG members throughout the process. Conclusions: We developed a comprehensive framework for estimating the global burden of FBDs, in which methodological simplicity and transparency were key elements. All the tools developed have been made available and can be translated into a user-friendly national toolkit for studying and monitoring food safety at the local level.

Summary Background The Global Burden of Disease (GBD) study assesses health losses from diseases, injuries, and risk factors using disability-adjusted life-years, which need a set of disability weights to quantify health levels associated with non-fatal outcomes. The objective of this study was to estimate disability weights for the GBD 2013 study. Methods We analysed data from new web-based surveys of participants aged 18–65 years, completed in four European countries (Hungary, Italy, the Netherlands, and Sweden) between Sept 23, 2013, and Nov 11, 2013, combined with data previously collected in the GBD 2010 disability weights measurement study. Surveys used paired comparison questions for which respondents considered two hypothetical individuals with different health states and specified which person they deemed healthier than the other. These surveys covered 183 health states pertinent to GBD 2013; of these states, 30 were presented with descriptions revised from previous versions and 18 were new to GBD 2013. We analysed paired comparison data using probit regression analysis and rescaled results to disability weight units between 0 (no loss of health) and 1 (loss equivalent to death). We compared results with previous estimates, and an additional analysis examined sensitivity of paired comparison responses to duration of hypothetical health states. Findings The total analysis sample consisted of 30 230 respondents from the GBD 2010 surveys and 30 660 from the new European surveys. For health states common to GBD 2010 and GBD 2013, results were highly correlated overall (Pearson's r 0·992 [95% uncertainty interval 0·989–0·994]). For health state descriptions that were revised for this study, resulting disability weights were substantially different for a subset of these weights, including those related to hearing loss (eg, complete hearing loss: GBD 2010 0·033 [0·020–0·052]; GBD 2013 0·215 [0·144–0·307]) and treated spinal cord lesions (below the neck: GBD 2010 0·047 [0·028–0·072]; GBD 2013 0·296 [0·198–0·414]; neck level: GBD 2010 0·369 [0·243–0·513]; GBD 2013 0·589 [0·415–0·748]). Survey responses to paired comparison questions were insensitive to whether the comparisons were framed in terms of temporary or chronic outcomes (Pearson's r 0·981 [0·973–0·987]). Interpretation This study substantially expands the empirical basis for assessment of non-fatal outcomes in the GBD study. Findings from this study substantiate the notion that disability weights are sensitive to particular details in descriptions of health states, but robust to duration of outcomes. Funding European Centre for Disease Prevention and Control, Bill and Melinda Gates Foundation.

Background The World Health Organization (WHO) initiative to estimate the global burden of foodborne diseases established the Foodborne Diseases Burden Epidemiology Reference Group (FERG) in 2007. In addition to global and regional estimates, the initiative sought to promote actions at a national level. This involved capacity building through national foodborne disease burden studies, and encouragement of the use of burden information in setting evidence-informed policies. To address these objectives a FERG Country Studies Task Force was established and has developed a suite of tools and resources to facilitate national burden of foodborne disease studies. This paper describes the process and lessons learned during the conduct of pilot country studies under the WHO FERG initiative. Findings Pilot country studies were initiated in Albania, Japan and Thailand in 2011 and in Uganda in 2012. A brief description of each study is provided. The major scientific issue is a lack of data, particularly in relation to disease etiology, and attribution of disease burden to foodborne transmission. Situation analysis, knowledge translation, and risk communication to achieve evidence-informed policies require specialist expertise and resources. Conclusions The FERG global and regional burden estimates will greatly enhance the ability of individual countries to fill data gaps and generate national estimates to support efforts to reduce the burden of foodborne disease.

Background Foodborne diseases are globally important, resulting in considerable morbidity and mortality. Parasitic diseases often result in high burdens of disease in low and middle income countries and are frequently transmitted to humans via contaminated food. This study presents the first estimates of the global and regional human disease burden of 10 helminth diseases and toxoplasmosis that may be attributed to contaminated food. Methods and Findings Data were abstracted from 16 systematic reviews or similar studies published between 2010 and 2015; from 5 disease data bases accessed in 2015; and from 79 reports, 73 of which have been published since 2000, 4 published between 1995 and 2000 and 2 published in 1986 and 1981. These included reports from national surveillance systems, journal articles, and national estimates of foodborne diseases. These data were used to estimate the number of infections, sequelae, deaths, and Disability Adjusted Life Years (DALYs), by age and region for 2010. These parasitic diseases, resulted in 48.4 million cases (95% Uncertainty intervals [UI] of 43.4–79.0 million) and 59,724 (95% UI 48,017–83,616) deaths annually resulting in 8.78 million (95% UI 7.62–12.51 million) DALYs. We estimated that 48% (95% UI 38%-56%) of cases of these parasitic diseases were foodborne, resulting in 76% (95% UI 65%-81%) of the DALYs attributable to these diseases. Overall, foodborne parasitic disease, excluding enteric protozoa, caused an estimated 23.2 million (95% UI 18.2–38.1 million) cases and 45,927 (95% UI 34,763–59,933) deaths annually resulting in an estimated 6.64 million (95% UI 5.61–8.41 million) DALYs. Foodborne Ascaris infection (12.3 million cases, 95% UI 8.29–22.0 million) and foodborne toxoplasmosis (10.3 million cases, 95% UI 7.40–14.9 million) were the most common foodborne parasitic diseases. Human cysticercosis with 2.78 million DALYs (95% UI 2.14–3.61 million), foodborne trematodosis with 2.02 million DALYs (95% UI 1.65–2.48 million) and foodborne toxoplasmosis with 825,000 DALYs (95% UI 561,000–1.26 million) resulted in the highest burdens in terms of DALYs, mainly due to years lived with disability. Foodborne enteric protozoa, reported elsewhere, resulted in an additional 67.2 million illnesses or 492,000 DALYs. Major limitations of our study include often substantial data gaps that had to be filled by imputation and suffer from the uncertainties that surround such models. Due to resource limitations it was also not possible to consider all potentially foodborne parasites (for example Trypanosoma cruzi). Conclusions Parasites are frequently transmitted to humans through contaminated food. These estimates represent an important step forward in understanding the impact of foodborne diseases globally and regionally. The disease burden due to most foodborne parasites is highly focal and results in significant morbidity and mortality among vulnerable populations., In this data synthesis, Paul Robert Torgerson and colleagues estimate the global and regional disease burden of 11 foodborne parasitic diseases., Editors' Summary Background Foodborne diseases cause a large burden of illness (morbidity) and death (mortality), worldwide. More than 200 diseases can be transmitted to people through the ingestion of food contaminated by microorganisms (viruses, bacteria, and parasites) or with chemicals. Food can become contaminated on the farms where crops and animals are raised, in food processing plants, and during food storage and preparation at home and in restaurants. Food contamination can be caused by pollution of water and soil by human and animal feces and by poor hygiene practices such as not washing one’s hands after using the toilet or before handling food. Many foodborne diseases present with gastrointestinal symptoms (stomach cramps, diarrhea and vomiting) but some also affect other parts of the body and some have serious sequelae (abnormal bodily conditions or diseases arising from a pre-existing disease). For example, the parasitic tapeworm Taenia solium (which is spread by eating undercooked pork) can cause cysticercosis, an infection of tissues by larval cysts that can result in seizures, stroke and death. Why Was This Study Done? National and international efforts to improve food safety need accurate information on foodborne infections so, in 2007, the World Health Organization (WHO) established the Foodborne Disease Burden Epidemiology Reference Group (FERG) to provide estimates of the global and regional burden of disease attributable to foodborne illnesses. Here, researchers involved in one of FERG’s constituent task forces—the Parasitic Diseases Task Force—combine information from many different sources (a data synthesis) to provide estimates of the regional and global disease burden of ten helminth diseases and toxoplasmosis attributable to contaminated food. Examples of helminths (parasitic worms) include roundworms (Ascaris lumbricoides; heavy roundworm infections [ascariosis] can cause signs of malnutrition or even intestinal blockages), tapeworms and flukes (liver and lung flukes cause a condition known as trematodosis; frequently transmitted in undercooked fish crustacea or aquatic vegetables). Toxoplasmosis is caused by a parasite found in undercooked meat and in cat feces. If a woman becomes infected during pregnancy, she can pass the parasite onto her unborn child (congenital toxoplasmosis), thereby causing eye problems and sometimes developmental problems and seizures later in life. What Did the Researchers Do and Find? The researchers combined national estimates of foodborne diseases, and data from systematic reviews (studies that identify all the research on a topic using predefined criteria), national surveillance programs, and other sources to estimate the number of illnesses, sequelae, and deaths for ten helminth diseases and toxoplasmosis. They also estimated the number of disability adjusted life years (DALYs) globally and regionally for each disease. A DALY is the disease-related loss of one year of full health because of premature death or disability; DALYs provide a measure of the burden of a disease. Together, these diseases caused 48.4 million cases of illness, 59,724 deaths, and 8.78 million DALYs in 2010. The researchers estimated that 48% of these cases of parasitic diseases, resulting in 6.64 million DALYs, were transmitted by contaminated food. The commonest foodborne parasitic diseases were Ascaris infection and toxoplasmosis (12.3 million and 10.3 million cases, respectively). Foodborne cysticercosis, trematodosis and toxoplasmosis resulted in the highest disease burdens, and the largest burden of foodborne parasitic disease occurred in the Western Pacific and African regions. What Do These Findings Mean? The lack of reliable data on the diseases considered in this study for many regions of the world and the use of expert panels to estimate the proportion of each disease that is foodborne may limit the accuracy of these findings. Moreover, this study does not estimate the global burden of every potentially important foodborne parasitic disease. However, these findings, together with those on three foodborne enteric protozoa (single-celled parasites that infect the intestines) included in a related paper, indicate that parasites are frequently transmitted to people through contaminated food and that, although some parasites result in a low burden of disease, foodborne parasites result in significant illness and death that is often borne by relatively small populations in limited geographical areas. This information, together with other estimates on foodborne disease obtained by FERG, should facilitate the development and implementation of effective national and global food safety policies. Additional Information This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001920. A related PLOS Medicine Research Article by Kirk et al that includes data on foodborne enteric parasites is available The World Health Organization provides information about soil-transmitted helminths, foodborne diseases, food safety, and the estimation of the global burden of foodborne diseases (available in several languages); it also provides fact sheets on cysticercosis, trematodosis, and ascariasis The US Centers for Disease Control and Prevention (CDC) provides information about foodborne disease outbreaks in the US and elsewhere and information about food safety in the US; it also provides general information about soil-transmitted helminths; more detailed information about individual diseases caused by helminths and about toxoplasmosis can be found by visiting the CDC’s alphabetical index of parasites The UK National Health Service Choices website provides information about roundworm infections and tapeworm infections, and about food safety PARA-SITE, an electronic resource devoted to parasitology that is provided by the Australian Society of Parasitology, provides more information about the biology of helminth parasites

The Go/NoGo association task (GNAT) has been used in behavioral studies to measure the strength of association between different category groups and two poles of an evaluative dimension. However, reaction time data do not provide information about the neural time course of such associative information. We investigated event-related brain potentials (ERPs) elicited when participants were required to respond (Go) or withhold a response (NoGo) according to task instructions. Task instructions paired words from one of two taxonomic categories (fruit/bugs) with either pole of an evaluative dimension (good/bad). Within a given run, Go responses were assigned to one of the categories and one evaluative dimension. ERPs showed an increased negativity over frontal sites to NoGo as compared to Go responses. Moreover, NoGo minus Go difference waves showed that the N200 effect was delayed in trials within incongruent blocks (e.g., "Press if a bug word or a good word") as compared to trials within congruent blocks (e.g., "Press if a bug word or a bad word"). These results suggest that such associative attitude information is available at a very early stage of processing, less than 250 ms after seeing a fruit or a bug word. This finding is further discussed with respect to alternative explanations of the behavioral effect.