International Food Safety Authorities Network (INFOSAN) Dr Richard Brown WHO Thailand

Priorities and Context for Health Security in the South-East Asia Region? Priority Hazards to Public Health in the SEA Region..? Emerging and re-emerging communicable diseases Anti-microbial resistance Food safety Increasing incidence / recognition of chemical events Natural disasters A changing context… Rapid development Increasing travel and industrialization Climate change

Food safety issues RED: microorganisms and contaminants BLUE: countries GREEN: food commodities

World Health Organization 23 April 2017 International foodborne disease outbreaks: Rapid spread worldwide by movement of food For example, in 2005, Sweden reported 80.2 percent and The Netherlands 87 percent of their salmonellosis cases acquired their infection while overseas (EFSA, 2007). 4

Globalisation of Trade : “The World on your Plate” World Health Organization 23 April 2017 Globalisation of Trade : “The World on your Plate” Herb Butter : Salted butter Garlic puree Garlic salt Lemon Parsley Pepper Water - Ireland - China, USA, Spain - USA - France, UK - Indonesia Chicken Breast: Chicken - Ireland, Belgium UK, France etc. Batter: Flour Water - Belgium, France - Ireland Bread Crumb: Bread crumb Rape-seed oil - Ireland, UK - EU, Australia Eastern Europe Chicken Kiev Courtesy A. Reilly, FSAI, Ireland 5

Some food safety challenges? World Health Organization 23 April 2017 Some food safety challenges? Contaminated food usually looks, smells and tastes normal Traditional (visual) food inspection is not sufficient Pathogens may survive traditional food preparation techniques New control techniques are required Infected animals often show no illness Public health initiatives must address apparently healthy animals Public health initiatives must include the safety of the food animals consume

What are the International Health Regulations (2005)? An internationally agreed instrument for global public health security Represents the joint commitment by all countries for shared responsibilities and collective defence against disease spread Legally binding for WHO Member States since June 2007 IHR (2005) provide the Asia Pacific Region with a unique opportunity to strengthen the fundamental public health system at both national and regional levels. .

Approach of the New IHR From controlling at borders, to containment ‘at source’ From a list of diseases, to a very broad range of threats Focus on ‘risk-based’ assessment & response New ‘infrastructure’ National IHR Focal points WHO IHR Contact Points in Regional Offices IHR Department in WHO Headquarters in Geneva, Switzerland Annual reporting to the World Health Assembly Secure Event Information Site (EIS) Emergency Committee and a ‘review process’

What does IHR implementation mean…? Two very important aspects… An immediate and ongoing requirement for countries to report some types of event when they occur, and for WHO to provide assistance A requirement, linked to a timeframe for countries to establish capacities to detect and respond to public health events (initially, by June 2012)

What should be reported to WHO? Any potential ‘Public Heath Event of International Concern’ (PHEIC) To help any decision, some criteria have been established Is the public health impact of the event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? Is there a significant risk of international travel or trade restrictions? A decision on whether to report an event will normally be made at national level (by the national IHR focal point) Only the DG of WHO (advised by experts) can declare a PHEIC

National IHR Core Capacities Requirements – Legislation and Policy – Coordination – Surveillance – Response – Preparedness – Risk Communications – Human Resources – Laboratory 3 levels – National – Intermediate – Peripheral/Community Potential Hazards Infectious Zoonosis Food safety Chemical Radio nuclear Events at Points of Entry

Hazard types of acute public health events reported to WHO, 2001-2012 From 2001 to date, around 4,285 acute public health events were managed by WHO worldwide, of which around 2600 could be substantiated. Infectious diseases of animal origin are predominant since 2007 which will continue considering close human-animal relationship. Almost one fourth of acute public health events were reported from the Asia Pacific Region (979 events) during last 12 years. Source: Event Management System WHO

As of today, there are 177 country members of INFOSAN What is INFOSAN? A global network of national food safety authorities that… Promotes the exchange of important food safety information globally Responds to international food safety events Helps countries strengthen their capacity to manage food safety risks with a goal of preventing foodborne disease Support capacity building on the reporting of international food safety events to the global community in collaboration with the WHO Global Foodborne Infections Network (GFN) As of today, there are 177 country members of INFOSAN INFOSAN (International Food Safety Authorities Network) is a global network of food safety authorities that promotes the exchange of food safety information globally, responds to international food safety events by sharing information and expertise, and helps countries strengthen their capacity to manage food safety risks with the goal of preventing the international spread of foodborne disease. The network is operates in collaboration with FAO and OIE.

INFOSAN Membership Emergency Contact Points  From the national authority responsible for coordination of national food safety emergency response Focal Points  Other national authorities with a stake in food safety (i.e. human health, animal health, agriculture, trade, fisheries, etc.) Other members  Advisory Group Members, WHO Regional Food Safety Advisors; FAO Regional Food Safety Officers; Regional Food Safety Authorities (i.e. ECDC, OIRSA, etc.)

World Health Organization 23 April 2017 Emergency Contact Point Roles and Responsibilities Reports urgent food safety events of potential international significance to the INFOSAN Secretariat Collaborates with their IHR National Focal Point on food safety events that fall under the IHR Assists the INFOSAN Secretariat in the verification and assessment of events by providing all necessary information, and reviews INFOSAN Alert messages pertaining to an event in their country Requests international assistance through the INFOSAN Secretariat to respond to a food safety incident or emergency, as necessary Takes action on INFOSAN Alerts and disseminates information accordingly

World Health Organization 23 April 2017 Focal Point Roles and Responsibilities Disseminates INFOSAN notes, FAO/WHO guidelines, and other important food safety information from INFOSAN within their agency, as appropriate Provides comments to INFOSAN on information products disseminated to the Network Engages in sharing information with the INFOSAN Secretariat and other members on food safety issues that may be relevant at the international level and beneficial to all members, including risk assessments on emerging hazards, lessons learnt, identified good practices, etc. Collaborates with INFOSAN Emergency Contact point on emergency events involving their respective agency

World Health Organization INFOSAN Collaborative Partnerships 23 April 2017 Global Early Warning System for Major Animal Diseases, including Zoonoses (GLEWS) World Organisation for Animal Health (OIE) Global Foodborne Infections Network (GFN) European Union - Rapid Alert System for Food and Feed (RASFF) EMPRES Food Safety WHO's Global Outbreak Alert and Response Network PulseNet International

The International Health Regulations and INFOSAN Disseminate Public Health Information Others sources Informal/Unofficial Information National IHR Focal Point and INFOSAN Emergency Contact Point IHR Reports Verification WHO Initial screen Public Health Emergency of International Concern (PHEIC) Assessment Event Risk Assessment It is important that the National IHR Focal Point and the INFOSAN Emergency Contact Point work in close collaboration to ensure national and international public health security and the fulfilment of the requirements under the IHR(2005), including the detection, assessment, notification, reporting, consultation and dissemination processes discussed in this Information Note. INFOSAN recommends that these collaborative agreements be documented. Notification and reporting One of the primary obligations for countries under IHR(2005) is to detect and assess events occurring within their territories by following the Decision Instrument and additional provisions provided in Annex 2 , and then to notify WHO of all such ‘events which may constitute a public health emergency of international concern’, within 24 hours of assessment, through their National IHR Focal Point. Some events relating to food safety will meet the criteria of the Decision Instrument and require notification to WHO under the IHR(2005). Such food safety events may relate to any of the three hazards which can occur in food; chemical, physical (sometimes know as foreign matter) and microbiological. Notification is the beginning of the assessment dialogue involving the country and WHO to determine the nature of the event and the appropriate response. The notification of an event must occur through the National IHR Focal Point. Surveillance and Verification WHO is mandated under the IHR(2005) to continue to carry out its surveillance activities taking into consideration information from sources other than notifications, assess events for international significance and to seek verification from the countries involved of unofficial reports or communications (e.g. the media) of potential events within their territories which may constitute a public health emergency of international concern. Countries must respond to WHO with an initial reply or acknowledgement within 24 hours and the public health information on the status of the event. Verification becomes the starting point for collaborative risk assessment and response. International Response After the assessment of public health information gained through surveillance activities, notification, consultation, other reports and verification processes, WHO is mandated to disseminate relevant information to National IHR Focal Points, including information necessary to enable countries to respond to a public health risk. The different provisions of the IHR(2005) relating to the identification and management of public health risks and events have application across a wide range of situations, the vast majority of which will never be determined to constitute a public health emergency of international concern (PHEIC). National Response The approach the IHR(2005) is for early detection and efficient communication in respect of public health events so that a timely assessment can be made regarding necessary response measures. The IHR(2005) require countries to develop and maintain their own response capacities24 and in addition, places obligations upon WHO to provide support to national response activities when required to do so. The nature of such support will vary considerably depending on a wide range of factors including the existing capacity of the national agencies, the level of international threat and the availability of expertise and resources. Additional technical and operational assistance to support national authorities may be coordinated through the Global Outbreak Alert and Response Network (GOARN) mechanism. GOARN is a technical collaboration of existing institutions and networks that pool human and technical resources to support the rapid identification, confirmation and response to outbreaks of international importance. The IHR(2005) calls upon WHO to work with its sister organizations, including FAO and OIE. FAO has an ongoing technical assistance programme to build capacity in the field of food safety and quality at national and regional level. FAO has also strengthened its capacity to react to emergency situations and support response at national and regional levels through the establishment of the Crisis Management Centre (CMC). Assistance / Response

Examples of INFOSAN Emergency ALERTS 2005 Salmonella in powdered infant formula from France to 13 countries 2006 E. coli 0157 in spinach from USA to all 150 member countries 2007 Shigella sonnei in baby corn – export from Thailand 2008 Melamine-contaminated powdered infant formula, China 2009 Outbreak of Salmonella Typhimurium in the USA linked to domestically produced peanut butter 2010 Outbreak of Thyrotoxicosis in Australia linked to internationally distributed soy milk from Japan 2011 Outbreak of haemolytic uraemic syndrome caused by enterohaemorrhagic Escherichia coli in Germany 2012 S. Bareilly and S. Nchanga Infections in the USA 2013 Outbreak of Hepatitis A infections in Denmark linked to frozen berries

Melamine-tainted milk – Concern for ALL! Melamine has a protein that includes "NITROGEN" (NPN)                               2007 –pet food and death 2008 – Kidney stone, deaths among infants in China The Chinese government 1st reported melamine-tainted dairy products in mid-September 2008. More than 3458 infants have been hospitalised with kidney stones in Beijing. Melamine powder was used as a cheap filler that can artificially inflate protein readings. Fresh milk distributed in Hongkong was based on dairy farming in Southern China. Many countries banned on Chinese milk and milk products but most of them have no technology to detect melamine in already imported milk products. China found melamine tainted 31 brands of milk products. 2.5 ppm legal limit for melamine in food products. China has burnt 32,200 tonnes of melamine-tainted dairy products in a bid to put a health scandal. More than 60 countries around the world banning or curtailing imports of dairy products from China. Melamine-tainted products: Sunflower products, eggs, biscuits and animal feed. INFOSAN provided further information on contaminated products from time to time. Cyromazine, a derivative of melamine, is widely used in pesticides and animal feed in China, and experts say it is absorbed in plants as melamine and that the chemical is already in the human food chain. Panic over food safety once link between melamine tainted milk and infant sickness was established 4 died and 50,000 left sick

INFOSAN Alert: Thyrotoxicosis from excess iodine in soy milk product On 23 December 2009, information received advising of 10 cases of thyrotoxicosis in one state of country ‘A’. Cases are linked to an imported soy milk product, brand X soy milk. Patients (particularly pregnant women) who report they have drunk the milk are advised to see their GP or obstetrician for a thyroid stimulating hormone (TSH) measurement. As iodine crosses the placenta it may cause foetal and neonatal hypothyroidism which can cause developmental problems in the newborn.

International Distribution of Soy milk United Kingdom Ireland Germany Japan Spain Cyprus Hong Kong Singapore Australia New Zealand

Hazard Characterisation Iodine content of the soy milk was 31 000 µg/L. = .031mg/ml TDI (Tolerable Daily Intake) - .017mg/kg body weight ~Adult body weight = 60 kg 0.017mg x 60 = 1.02mg TDI (Adult) 1.02/.031= 32.9ml Exposure over 32.9ml per day will exceed TDI (1 cup is 250ml) (adult)

Risk Assessment Hazard identification Exposure assessment Excessive iodine consumption has been linked to clinical thyrotoxicosis and, less commonly, hypothyroidism. Epidemiological information and analysis 31 000 µg/L iodine in milk Hazard identification Exposure assessment Hazard characterisation Risk characterization Imported food product (Brand) Tolerable daily intake is likely to be exceeded if 33ml is consumed per day by an adult. 9 adult, 1 infant affected National and international distribution Tetra Pack (Shelf Stable) Intake can vary from use in tea/coffee or as a milk drink Average quality of intake not clear The commonest symptoms are - Low muscle tone - Jaundice - Poor feeding - Constipation - Sleepiness/sluggishness - Hypothermia (reversible) Iodine can cross the placenta and may cause foetal and neonatal hypothyroidism which can cause loss of cognitive functions (irreversible)

Take home messages! Build national INFOSAN networks (ensuring farm-to-table representation) and increase their operational capacity Enhance communication between INFOSAN Emergency Contact Points and National IHR focal point