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

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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 gree

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