Food toxicity in Pakistan: a mini-review on foodborne diseases

Introduction Food toxicity, also termed foodborne illness, is an infection or irritation of the digestive tract, which results from the consumption of contaminated or toxic food1. Microorganisms, such as Salmonella, Campylobacter, Enterohaemorrhagic Escherichia coli (E. coli), Listeria, and Cholera are major causes of foodborne diseases2. Accumulation of organic pollutants and metals (like lead and mercury) in food stores also leads to food toxicity2. Although symptoms of food poisoning vary depending on the causative organism or chemical toxin, a few symptoms like diarrhea (bloody or watery), vomiting, abdominal pain, fever, and headache are commonly found3. In addition, food toxicity could lead to malabsorption syndromes like tropical sprue, Whipple disease, celiac disease, and lactose intolerance4,5. In recent years, foodborne illnesses have been rising worldwide with the situation being especially grave in developing countries, like Pakistan6. The World Health Organization (WHO) estimates that 600 million people, almost 1 in every 10 people worldwide, fall sick after ingesting contaminated food, while 420,000 people die annually7. In addition, children under the age of 5 are the most affected, as they account for 30% of all food toxicity-related deaths, despite only contributing 9% to the world population8. Furthermore, the incidence of foodborne illness seems higher in Southeast Asian countries like Pakistan, where poor sanitation, improper food handling, and limited availability of clean water are all major factors contributing to food toxicity9. Apart from the health toll, food toxicity also places an enormous burden on a country’s economy, and WHO estimates a loss of USD 110 billion each year in low and middle-income countries due to decreased productivity and medical expenses associated with food toxicity7. Common foodborne diseases in Pakistan include hepatitis, typhoid, animal contact, and influenza. Research data indicate that contamination from microbial sources is more common than chemical, with Salmonella being the most common pathogen9. The incidence of Salmonella in Pakistan is among the highest in the world, with 412 per 100,000 cases being reported annually10. Recently, there has been increased consumption of ready-to-eat (RTE) food, including burgers, shawarma, pizza, and sandwiches. A study from Quetta reveals that almost 38% of RTE food was not fit for human consumption11. Increased consumption of fruits and vegetables also contributes to the rising food toxicity cases because despite being essential components of a healthy diet, they are often mishandled and contain various toxins ranging from human pathogens like Salmonella and E. coli to agricultural pesticides like carbamates9. These can lead to comorbidities like acute gastritis, heart diseases, organic failure, and arthritis9. Similarly, consuming seafood contaminated with mercury could lead to neurological and psychological symptoms, including tremors, motor/cognitive dysfunction, and memory loss9. Despite the increasing incidence of food toxicity, Pakistan still faces much uncertainty regarding the actual number of food toxicity cases, mainly due to underreporting of cases and poor surveillance capacity6. Uncertainty, regarding the issue’s extent and severity, makes it difficult to combat it6. To make matters worse, misuse of antibiotics in hopes of alleviating symptoms of food poisoning has further intensified the health issues while giving rise to new drug-resistant strains6. Therefore, this article discusses the prevalence of foodborne diseases in Pakistan and their impact on public health. In addition, it highlights the need for immediate action, current efforts being made, and recommendations that could be implemented to counter some of the challenges. Methods For this paper, the databases Google Scholar and PubMed have been used, and the keywords “Food Toxicity,” “Diseases,” and “across Pakistan” were used. Additional searches were “Food Contamination” and “Foodborne diseases.” All article types, that is, observational, editorial, and review studies respective to the literature search, have been included in this narrative review. Literature that does not correspond to situations in Pakistan or diverts away from the keywords is excluded, as well as any duplicates. Results The literature search applying the methodology yielded studies based on prevalence, challenges, prevention, and treatment regarding food toxicity and foodborne diseases in Pakistan. In Pakistan, studies have shown that most cities in Sindh, Punjab, and Khyber Pakhtunkhwa have prevalent foodborne diseases, such as typhoid, enteric fever, gastroenteritis, gastric ulcer, and gastrointestinal cancer. There is also a prevalence of symptoms like watery or bloody diarrhea, vomiting, nausea, and abdominal pain. The preventive and treatment measures include proper surveillance of food sanitation through inspection services and individualistic efforts to consume healthier and cleaner foods. Consequently, 25 studies have been yielded to cite in this study. Challenges and prevalence In 2015, WHO reported estimates of disease burden because of 31 foodborne pathogens leading to over 600 million cases of foodborne illnesses and 420,000 deaths in a year12. The burden of foodborne diseases is felt more in vulnerable groups, children under 5, and individuals from the middle and lower social classes12. A 2019 World Bank report estimated an annual USD 15 billion that went towards treating foodborne diseases7. On ingestion, food contaminated by bacteria, parasites, viruses, chemicals, as well as bio-toxins, pose a serious threat to the health and well-being of individuals2. Unsafe food can result in over 200 diseases, ranging from diarrhea to cancer. An estimated 66% of foodborne illnesses are a result of bacterial pathogens, with chemical agents causing 26%, followed by ~4% due to parasites and viruses in Pakistan13. A 2018 cross-sectional study of 800 participants in Sindh, a province in Pakistan, reported a 19% prevalence of Salmonella, 28.99% Listeria monocytogenes, and 8% in Campylobacter jejuni and E. coli6. These bacteria produce symptoms, such as fever, headache, nausea, vomiting, abdominal pain, and diarrhea6. Salmonellosis is a disease caused by the bacteria Salmonella which has been associated with foods of animal origin, such as eggs and poultry. Another similar pathogen is Salmonella typhi which has caused a surge in typhoid fever cases within Pakistan14. The pathogen enters through the fecal-oral route and is often associated with poor food sanitation14. Campylobacter cases arise from contaminated meat and meat products making this pathogen the leading cause of diarrhea and gastroenteritis in humans. A 600 sample of meat collected from Lahore showed the prevalence of Campylobacter in chicken (29%), mutton (18%), and beef (15.5%)15. E coli is linked to unpasteurized milk, undercooked meat, and contaminated fresh fruits and vegetables6. Listeria infections are among the most serious, affecting infants, children, elderly, and it has been associated with miscarriages in pregnant women6. This bacterium is typically found in unpasteurized dairy products and various RTE foods and can grow at refrigeration temperatures. Antibacterial agents are used to treat such infections; however, the overuse and misuse of such medication, which is highly common in Pakistan, has caused the development and spread of resistant strands resulting in effective treatments6. Norovirus is among the most common causative agents of foodborne illnesses, comprising about 44% of foodborne diseases. The virus is associated with nausea, explosive vomiting, watery diarrhea, and abdominal pain. Along with astrovirus, norovirus is the leading cause of gastroenteritis in children within underdeveloped countries. However, despite early youth mortality because of severe gastroenteritis, prevalence rates in Pakistan are underreported6. Leafy greens, fresh fruits, and shellfish are the most common source of norovirus infections6. Naturally occurring toxins, such as mycotoxins, which are commonly found in corn and cereals can lead to cancer upon long-term exposure. Persistent organic pollutants, such as dioxins, are hazardous byproducts of industrial and waste incineration practices, which accumulate in the food chains. These toxins produce damaging effects on the reproductive and developmental processes and immune system and are carcinogenic12. Furthermore, neurological, and renal dysfunction occurs because of foods grown in soil contaminated with heavy metals, such as lead and mercury12. Radioactive nucleotides are hazardous chemicals released from industrial or military procedures, which can go on to contaminate the soil as well7. Animal contact along with soil contact diseases are common in Pakistan. Several factors, such as unhygienic conditions, lack of proper food standards, poor sanitation, poverty, and literacy instigate the spread of foodborne illnesses13. Due to poor surveillance, most outbreaks in Pakistan related to foodborne pathogens go unreported, posing a serious health concern. Such concerns intensify as globalization of food supply, street vendors and open sewages facilitate the spread of such pathogens into the environment. As the majority of Pakistan’s population lives below the poverty line, they are exposed to poor living standards, improper infrastructure, and a polluted environment, which further promotes foodborne illnesses. A sample of 282 various types of foods was collected by a study within Pakistan, which shed light on a high number of pathogenic organisms present. Food samples collected from streetside shops and vendors were 70% contaminated, whereas middle and upper-class restaurants were 40% contaminated with microbial agents13. As Pakistan enters the festive season of Eid-Ul-Adha every year, the cases of Crimean Congo hemorrhagic fever (CCHF) associated with livestock surge16. This illness is spread through ticks carrying the nairovirus. WHO has ranked Pakistan fourth in the Eastern Mediterranean Region for CCHF. The prevalence of the disease within Pakistan is 38% in Baluchistan, 3% in Punjab, 14% in Sindh, and 14% in the province of Khyber Pakhtunkhwa16. To limit the spread of CCHF, the health of animals should be assessed and reported, local authorities should ensure appropriate removal of waste and carcass of the slaughtered animals and essential equipment for diagnosis, and treatment of the disease should be accessible at the district level in addition to appropriate pest control measures should be taken16. Furthermore, Orf disease (also known as contagious pustular dermatitis or ecthyma contagiosum) is yet another illness that may arise due to contact with sheep and goat meat. This particular disease is due to the parapox virus which typically presents as a solitary lesion, such as an ulcer or nodule on hands and feet17. To limit foodborne infections, food should be thoroughly cooked, failure to do so results in conditions, such as but not limited to diarrhea and dysentery. To reduce the prevalence of such diseases, the importance of good hygiene and sanitation must be emphasized by the general public. Furthermore, the government must work towards developing infrastructure to protect the soil and irrigation of crops from toxins seeping in from sewage or industrial waste. Shortcomings in policymaking and equipment are associated with poor food security in Pakistan. A surveillance system should be developed to track outbreaks of foodborne illnesses, as well as report food safety issues and the burden of such diseases. Self-medication leading to abuse or improper use of antibiotics should be limited to avoid antimicrobial resistance within the population. Such practices reduce the risk of foodborne diseases, and a lack of awareness of the issue favors the mortality and morbidity rates associated with such illnesses6. Recommendations and efforts Various organizations worldwide are working towards ensuring food safety and distribution. The one that is the most front and center is WHO, which works towards preventing foodborne diseases across the globe. Other significant contributors to food safety are the U.S. Food and Drug Administration, the U.S. Department of Agriculture, the Barilla Centre for Food and Nutrition, the Australian International Food Security Centre, etc18,19. It is the foremost responsibility of the food authorities but also need backup support from the local citizens. People should avoid the consumption of street foods, reduce the frequency of eating out, and practice the habit of preparing food at home more frequently. However, with most people working at low wages, street food is their primary option, which is cheaper and fulfilling at the same time. So, in addition, there should be increased awareness which would aim to motivate street vendors to employ proper hygienic methods while preparing food. The proper hygiene practices, that is, washing hands after using the toilet and before preparing food, using protective gloves and masks when handling food, and using either disposable cutlery or properly washing reusable cutlery for serving. Food should be properly cooked thoroughly, utensils thoroughly washed, and only boiled/chlorinated water should be opted20. Eating a small amount of nutritious food is always better than eating small or large amounts of junk food, that is, no matter how much a person eats, it will always be unsafe if the quality has been compromised21. In view of current safety issues, there is a need for food inspection authorities to take charge and shed more light on guaranteeing better quality in addition to enhanced quantity. Outbreak investigations should be practiced, which help in the prevention of foodborne diseases through research and investigation of the underlying cause, that is, finding the root of the problem, hence ensuring better control22. Moreover, food authorities have been set up in Pakistan, each working at a provincial level. They are doing a much better job of ensuring food safety than Pakistan’s food and agriculture department. However, not all are fully active, which further leads to compromises in food quality. All in all, there is a lack of a legal framework for food safety for native, as well as overseas food trade23. According to the 2020 Global Food Security Index, which measures 59 factors on the state of food affordability, availability, quality, safety, and natural resources/resilience in 113 countries, Finland was ranked top for food security, ahead of the Netherlands and Ireland. Among the top rankers were the UK, United States, and Canada, which came 6th, 11th, and 12th, respectively24. Finland works alongside the motto, “Sustainable management of natural resources is fundamental to all development.” Finland has climbed up to the top in terms of food safety as it supports developing countries through the improvement of the agricultural system, ensures a reliable and safe water and sanitation system, practices the employment of renewable energy resources, and promotes forest development to counteract the drastic impacts of climatic change25. Not surprisingly, these conditions correlate with Pakistan as well. Pakistan is also a developing country with agriculture as the mainstay of income and feeding the local population. Pakistan can easily adopt the approach taken by Finland by the development of the agricultural industry through research, education, and provision of better equipment; by using renewable energy resources due to the sunny climate being prevalent most of the year for the use of solar panels, the availability of coastlines and high tides for hydroelectric and tidal power generated electricity, and to organize and support plantation schemes. The food inspection authorities should also become more active in their aim. Conclusion Recently, there has been a rise in food toxicities in Pakistan, leading to the spread of foodborne illnesses, such as hepatitis, typhoid, animal contact diseases, and influenza. Most of these foodborne illnesses result from viral, parasitic, and bacterial pathogens, with Salmonella being the most common pathogen, which causes symptoms, such as fever, headache, nausea, vomiting, abdominal pain, and diarrhea. Several factors, such as unhygienic conditions, absence of proper food standards, poor sanitation, contamination with inorganic and metallic toxins, poverty, and literacy instigate the spread of foodborne illnesses in Pakistan. Therefore, there is a need for better surveillance systems to track outbreaks of foodborne illnesses, report food safety issues, and ensure adequate infrastructure especially crop irrigation farms that are free from sewage or industrial waste contamination. In addition, the abuse or improper use of antibiotics should be limited to curb the spread of antimicrobial resistance in Pakistan. Ethical approval Not applicable. Sources of funding Not applicable. Author contribution All authors made substantial contributions to the manuscript. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) Not applicable. Guarantor Abdullah Malikzai.

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