key: cord-0813060-19q1nwab
authors: Schlundt, J.
title: Institutions Involved in Food Safety: World Health Organization (WHO)
date: 2014-01-13
journal: Encyclopedia of Food Safety
DOI: 10.1016/b978-0-12-378612-8.00008-1
sha: 67f5f4c3ce580bd04a60e406905a0f5b3b8db2af
doc_id: 813060
cord_uid: 19q1nwab

The World Health Organization (WHO) has been a leading intergovernmental organization in the effort to prevent diseases related to food and improve global food safety and security. These efforts have been focused on the provision of independent scientific advice on foodborne risks, the development of international food standards, through the work of the Food and Agricultural Organization of the United Nations/WHO Codex Alimentarius Commission, and the support of Member States through direct policy advice as well as through the creation of laboratory and authority networks sharing experience and building capacity. WHO has also promoted the development and spread of new policy thinking in the food safety area, including especially the introduction of the new risk analysis paradigm, the holistic, farm-to-fork thinking in relation to food production, now often referred to as ‘One Health,’ and finally the focus on simple and efficient messaging toward preventing food risks through a better understanding of good food preparation practices in all sectors.

Foodborne disease (FBD) continues to be a major public health issue. Food safety and FBDs have implications both on the health of individuals and the development of societies. Concerned by this, the Sixty-Third World Health Assembly (WHA), the governing body of the World Health Organization (WHO), in May 2010 reminded the Director-General of WHO of the need for efficient gathering and exchange of information in and among countries; and adopted a resolution 'Advancing Food Safety Initiatives (WHO, 2010) .' The resolution asked Member States to establish disease burden estimation and surveillance and to contribute to the timely conduct of international risk assessments through the provision of relevant data and expertise. And specifically the resolution called upon the Director-General of WHO to help countries build relevant capacity to improve cross-sectoral collaboration along the whole food production chain and to establish with the International Food Safety Authorities Network (INFOSAN) an international initiative for the collaboration of laboratory partners in support of surveillance of FBD, identification of food contamination, and emergency response, including outbreak investigation.

WHO's central role in food safety as well as in other public health areas is a normative one and includes the facilitation of risk assessment and international standard setting. The most thorough normative change over the past decades in the food safety area has been the introduction of a formalized system to prepare and utilize science-based risk assessments to improve the safety of food, both at international and national level. For almost 20 years, WHO has promoted the new concept of risk analysis as a framework for the management of food production and food safety. Developed by WHO in collaboration with the Food and Agricultural Organization of the United Nations (FAO), the risk analysis framework and principles are depicted in Figure 1 . Within this framework it is important to achieve functional separation of risk assessment (the science) and risk management (the intervention). The final goal of assessment should be to inform risk managers and other stakeholders of the nature, occurrence, and size of the risk in order to improve the quality of risk management decisions.

New concepts were needed because the old food safety systems have failed in the sense that the incidence of FBDs seems to have increased over the past decades in most countries. One of the reasons for this has been the intuitive reliance on testing. It must be realized that safety cannot be achieved by monitoring the presence of pathogens in the end product because it is impossible to test sufficient samples to obtain the necessary degree of statistical power to detect all contaminants at levels that may create unacceptable health risks. Therefore, a proactive approach is required, starting with the producer, including in many cases the primary production sector, ensuring a safe product based on predictive risk assessment and, where relevant, implementation of action plans to lower the prevalence of relevant pathogens.

The main focus of WHO's work in the area has been the development of methods for quantitative microbiological and chemical risk assessment, FBD surveillance, and also the assessment of the safety of new products used in food, including genetically modified (GM) foods. The use of risk assessment to improve risk management decisions and risk communication to enable transparent and proactive interaction between all interested parties, constitute the two other components of the risk analysis framework.

The Structure of WHO Relative to Food Safety Work WHO's food safety activities extend from the WHO headquarters (HQ) in Geneva, Switzerland, often through six Regional Offices: AMRO (Regional Office for the Americas), AFRO (Regional Office for Africa), EMRO (Regional Office for the Eastern Mediterranean), EURO (Regional Office for Europe), SEARO (Regional Office for South-East Asia) and WPRO (Regional Office for the Western Pacific). The regional structure of WHO stems historically from the creation of WHO in 1948, where the preexisting Pan-American Health Organization was included in WHO as AMRO with an existing, independent governance structure. This independent structure was replicated in the other five regional offices, thereby creating an organization with not one, but seven politically appointed heads. In effect this means that each Regional Director is independently elected, and thus in effect can define policy course on his or her own. The regional offices receive approximately 75% of the WHO's budget and because regional directors are not appointed by or formally responsible to the WHO's Director-General, criticism has been voiced that some of the agency's activities are uncoordinated and not based on the best scientific evidence.

Over the later years, WHO has seen significant cuts in its budget. Therefore, a number of technical departments in the WHO HQ have seen cuts in technical staff. But even before these cuts the technical area of food safety was small in the WHO HQ as well as in regions. At its peak in 2008, the Department for Food Safety and Zoonoses at the WHO HQ included approximately 12-14 scientific staff and 6-8 other staff, whereas the regional offices typically had less than 1 scientific staff in this area. At the third layer of the organization, the country offices, food safety is typically covered by staff, who also cover a number of other technical areas. Nevertheless, the WHO has been able to support significant development in national food safety programs, and shoulder a very significant work load in the area, primarily through the active support of -mostly nationally funded -scientists from all over the world.

Most of the WHO work in the food safety area is conducted in some sort of collaboration with FAO. In the 1990s, the collaborative efforts between the two organizations were somewhat hampered by policy disagreement and to some degree by personal fights between WHO and FAO staff, including staff at senior level. Under the administration of WHO Director-General Dr Gro Harlem Brundtland, WHO in the late 1990s introduced the 'farm-to-fork' collaborative line with FAO, a policy line mirrored by FAO. This did not mean that the two organizations necessarily agreed in all policy areas, but a cooperative effort was underlined in most areas of work. Following the major zoonotic outbreaks in the first decade of 2000, including severe acute respiratory syndrome (SARS), avian influenza, and type H1N1 influenza, the collaboration between FAO and WHO was extended to also include the World Animal Health Organisation (OIE).

The collaborative efforts between WHO and FAO in the area of provision of scientific advice include three expert groups with relatively regular meetings. These groups are managed differently, but all in collaboration between WHO and FAO. They are the Joint FAO/WHO Expert Committee on Food Additives and Contaminants (JECFA), the Joint FAO/WHO Meeting on Pesticide Residues (JMPR), and the Joint FAO/WHO Expert Meetings on Microbiological Risk Assessment (JEMRA). For further description of the work of these joint committees, see the article on FAO, or visit:

1. http://www.who.int/foodsafety/chem/jecfa/publications/ en/index.html (JECFA).

Risk communication * Science based * Policy based * Interactive exchange of information and opinions concerning risks Figure 1 The WHO/FAO risk analysis paradigm, with risk assessment independent from undue influence from risk managers, and with everything floating in a sea of risk communication.

2. http://www.who.int/foodsafety/chem/jmpr/publications/ en/index.html (JMPR). 3. http://www.who.int/foodsafety/micro/jemra/en/ (JEMRA).

In addition to these expert groups, FAO and WHO have hosted a number of ad hoc expert meetings in relation to food safety issues. An example of such an ad hoc expert meeting is the Ad hoc Expert Group on Food Safety Risk Assessment of GM Food, which is described in an other article.

Whereas the expert groups described above all typically respond to specific requests for scientific advice, in most cases from the FAO/WHO Codex Alimentarius Commission (CAC), WHO has in a number of cases initiated scientific work without such request. The examples are manifold, but three important examples shall be briefly described here.

issue that is impacted by both human and nonhuman antimicrobial usage. The continuing emergence, development, and spread of pathogenic microorganisms that are resistant to antimicrobials are a cause of increasing concern. WHO's involvement in the containment of AMR due to nonhuman antimicrobial usage dates back to the late 1990s, and includes the hosting of a number of expert meetings from 1997 to this day. Although the other relevant international organizations in this area -FAO and OIE -were not immediately supportive of the suggestions coming out of these expert meetings, through continued efforts from WHO the issue has since 2007 also been included in CAC work. These efforts have led to clear recommendations about prudent use of antimicrobials in animals as well as a description and selection of critically important antimicrobials. Whereas some recommendations have been implemented in some parts of the world, a very significant number of recommendations have not. In most countries, antimicrobials are still used as growth promoters, and veterinarians are still allowed to make profits from selling such drugs. 2. Acrylamide was until 2002 considered an occupational health issue only, as this substance had not been found in food. Therefore, it was considered dramatic news when Swedish researchers in March 2002 unveiled research showing very high concentrations of acrylamide in ordinary food items, such as French fries, bread, and coffee. Although some experts dismissed the importance of these findings -for example, with statements about how 'we have eaten these types of food for centuries' -WHO maintained a serious attitude toward these findings relative to a substance that had been proven carcinogenic in animals. Thus, a WHO/FAO expert consultation was undertaken less than 2 months after the Swedish news. The consultation considered that the available data suggested that toxicological findings in animals should be assumed to be relevant for extrapolation to humans. The consultation also provided a range of recommendations for further information and new studies to better understand the risk to human health posed by acrylamide in food.

System obtained information from the Chinese Ministry of Health (MoH) that a serious and widespread contamination event had occurred in China. The contamination of infant formula with melamine had been spurred by fraudulent use of melamine to disguise the dilution of milk with water. Through further interaction between INFOSAN and MoH the issue of potential other use of the contaminated milk powder as well as parallel (illegal) distribution of contaminated milk powder to other countries was investigated. An INFOSAN Emergency Alert was distributed to the network and subsequently updates were issued regularly during the following months. A WHO Expert Meeting was held in collaboration with FAO a few months after the event unfolded in an effort to elucidate the normal ('baseline') exposure of humans to melamine, as well as suggest relevant tolerable daily intakes of melamine through food.

People in ancient times already understood they could get sick from consumption of infected meat, and that keeping their animals healthy and using dedicated methods of food preparation and conservation could improve their health. Maybe the oldest written document about this, 'On Airs, Waters, and Places' is by Hippocrates that describes how human health is influenced by its interaction with the environment. A clear understanding of the importance of food and food safety for health led to the creation of the FAO/WHO Food Standards Programme in 1963, the active arm of which is the FAO/WHO the CAC. The CAC now meets once a year and agrees on food standards, guidelines, and codes of practice, typically developed in one of its 16 committees and task forces. However, the CAC system had become a very heavy system with significant bureaucracy. Realizing this, WHO and FAO in 2001 initiated an evaluation, resulting in some, but not very profound changes, including a higher level of inclusiveness especially toward developing countries. However, the system has also proven a capacity to move fast, even when dealing with politically charged issues. For example, the development of guidelines for the assessment of GM foods was finalized within a time period of only 4 years. When considering that such standards are developed based on several FAO/WHO expert meetings, as well as several task force meetings, many times with the participation of 50-70 countries, this is actually an impressive international achievement.

Because the work of CAC is governed by the member countries, the system typically does not deal immediately with new or upcoming issues, unless key member countries take a direct interest in this. An example of an important food safety issue that has only been taken up reluctantly by CAC is the problem of AMR in microorganisms. Later in this article, forward-looking initiatives by the WHO in this area will be described, but it is noteworthy that it was only in 2007 that CAC agreed to start an initiative in this area, i.e., the Codex AMR Task Force.

Although CAC standards and guidelines are in effect just voluntary guidance documents, the specific reference to CAC in the World Trade Organization agreements as the 'gold standard' in the food safety area has meant that most countries take CAC guidance seriously. Nevertheless, CAC standards and guidelines have no legal status above this. However, WHO has an international legal instrument that covers certain aspects of food safety, the International Health Regulations (IHR), which is a legally binding agreement for all 194 Member States of the Organization. The aim of these regulations is to help the international community prevent and respond to acute public health emergencies that have the potential to cross borders and threaten people worldwide. Such public health emergencies include risks related to food, because diseases can spread far and wide via international food trade. A health crisis in one country can impact the health, livelihoods, and economies in many parts of the world. The IHR aims to reduce unwarranted interference with international traffic and trade, while ensuring public health through the prevention of disease spread.

The present IHR, which entered into force on 15 June 2007, require countries to report certain disease outbreaks and public health events to WHO. Building on the unique experience of WHO in global disease surveillance, alert, and response, the IHR defines the rights and obligations of countries to report public health events, and establish a number of procedures that WHO must follow in its work to uphold global public health security. Thus, countries have an obligation to inform the global community, through WHO, about any public health risk related to food, which has the potential to cross borders or that are otherwise unique. WHO has created a specific system for the reporting of such food safety events: The INFOSAN, which operates in collaboration with FAO, is described in this article under the section 'Food Safety Emergency Action and Exchange of Experience over Borders.'

Although important parts of international food safety work involves the collaborative WHO-FAO framework, a number of issues related more specifically to the occurrence, surveillance, and prevention of FBD are primarily supported at the international level by WHO. FBDs result from the ingestion of contaminated foods and food products and include a broad group of illnesses caused by biological and chemical agents, which contaminate food at different points in the food production and preparation process. In work sponsored by the WHO FBD Burden Epidemiology Reference Group (FERG), it was estimated that in 2008, 1.336 million children under the age of 5 years die every year from diarrhea caused by contaminated food or water. Consequently, diarrhea is the second leading cause of death among children after respiratory diseases. In 2009, another FERG-sponsored study estimated that diarrhea-related deaths among adolescents and adults were 1.15 million per year. The total mortality of 2.486 million deaths due to diarrhea is more than deaths due to AIDS, malaria, and measles combined.

As usual the poorest part of the population is at the highest risk: In general, malnutrition can result in a 30 fold increase in the risk for diarrhea-associated death. When considering these estimates of child deaths, it is important to realize that they do not include deaths in other age groups, deaths as caused by foodborne microorganisms not resulting in diarrhea nor the probably very significant disease burden caused by chemical substances, including naturally occurring chemical substances in food. Such chemical substances include aflatoxins caused by fungi growing in food as a result of poor storage conditions, or acrylamide formed in certain foods when heated 41201C.

Although most diarrheal deaths occur in poor countries, FBDs are not limited to developing countries. It is estimated that, in 2011 in the USA, FBDs resulted in 48 million illnesses (one in six people), 128 000 hospitalizations, and 3000 deaths per year resulting in medical costs and productivity losses in the US$ billions. The full extent of the burden and cost of unsafe food is currently still unknown, but its impact on global health security, trade, and development is considered to be profound. Thus, valid estimations of the real FBD burden are basically nonexistent. Recognizing the current data gap, WHO has launched an Initiative to Estimate the Global Burden of FBDs from all major causes using summary health metrics that combine morbidity, mortality, and disability in the form of the disability-adjusted life year. This has been initiated through the establishment of the FBD Burden Epidemiology Reference Group (FERG). The FERG members are mandated to engage in assembling, appraising, and reporting on currently existing burden of FBD estimates, conducting epidemiological reviews for mortality, morbidity, and disability in each of the major FBD, providing models for the estimation of FBD burden where data are lacking, developing source attribution models to estimate the proportion of diseases that are foodborne, and developing userfriendly tools for burden of FBD studies at country level. Although the work of FERG was originally stipulated to result in (some) global FBD data by 2012, the work is still ongoing, and parts of the work seem hampered by recent funding trouble.

In 2000, the Fifty-Third WHA recognized the serious threat to public health posed by foodborne illness and called for improved 'gathering and exchange of information in and between countries and regions on matters of food safety' . The Fifty-Fifth WHA in 2002 expressed serious concerns about health emergencies posed by natural, accidental, and intentional contamination, including food contamination, and requested WHO to coordinate the identification of and response to such emergencies.

In 2004, in response to the aforementioned resolutions and in reply to a specific request made by the FAO/WHO CAC, WHO established the INFOSAN, in collaboration with FAO. The network was built to help Member States deal with international food safety incidents and emergencies, and to facilitate communication and information sharing among all food safety stakeholders. Currently, 167 Member States are members of INFOSAN.

The INFOSAN network not only responds to the reporting of human FBD cases to WHO, but also provides information to countries when a food contamination event has the potential to affect human or animal health at a later stage. To promote seamless action throughout the food chain continuum, INFO-SAN and the Global Early Warning System (GLEWS) for Major Animal Diseases, including Zoonoses exchange information directly. GLEWS is a confidential early warning network of WHO, FAO, and OIE used to track, verify, and analyze transboundary zoonotic diseases. This network brings together the expertise of the three different organizations to maximize prevention and control of zoonotic diseases. INFOSAN and GLEWS coordinate efforts relative to food safety events linked to animal health (e.g., avian influenza), animal feed (e.g., aflatoxin), or farm practices (e.g., AMR).

In addition to emergency information, INFOSAN facilitates the exchange of food safety information and experience among its members through the publication of INFOSAN Information Notes, in the six official WHO languages. These Notes provide INFOSAN members with summaries on relevant food safety issues. This INFOSAN function is supplemented with capacity building efforts aimed at the building of integrated food safety systems able to manage and monitor events with national or international implications.

WHO has for a number of years hosted the first ever global database for food contamination, focused on chemical contaminants. The Global Environment Monitoring System-Food Contamination Monitoring and Assessment Program (GEMS/Food) was established in 1976 to inform national governments, CAC, and other stakeholders, as well as the public, on levels and trends of chemical contaminants in food and their contribution to dietary exposure. The program operates through a network of WHO Collaborating Centers and national institutions located in approximately 70 countries around the world. National data are submitted to GEMS/Food to conduct international scientific assessments of exposure, as part of chemical risk assessment. In addition, WHO has developed an approach to describe the various diets around the world. The GEMS/Food Consumption Cluster Diets were updated in 2006 and are now used both nationally and internationally for exposure assessment of food contaminants and pesticide residues (Figure 2 : WHO GEMS/Food Consumption Cluster Diets).

Recognizing an urgent need for building Member State capacity in surveillance of foodborne and other enteric infections from the farm to the table, the WHO in 2000 initiated the WHO Global Salm-Surv, now called Global Foodborne Infections Network (GFN). The network promotes integrated, laboratorybased surveillance, and fosters intersectoral collaboration and communication among microbiologists and epidemiologists in human health, veterinary, and food-related disciplines. The network has been created with the support of some of the most respected national laboratories in these areas from a long list of WHO Member States, including Australia, Canada, Denmark, France, Germany, Japan, Netherlands and the USA.

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. By May 2012 the GFN included 1062 members from 184 Member States, and continuous activities covering: regional training courses on FBD surveillance, risk assessment and epidemiology, external quality assurance programs on microbiology, reference testing of selected foodborne pathogens, and provision of technical information and methodological support for microbiological laboratories. The GFN also hosts a country data bank with data on national Salmonella isolates from more than 83 countries comprising approximately 1.5 million human and 360 000 nonhuman isolates.

WHO considers new activities linking databases covering microbiological and chemical contaminants in food in an effort to promote the sharing of food contamination data among countries.

The future food safety systems will most likely enable new ways of evaluating disease metrics and attribute such disease directly to food groups. It is likely that new genetic fingerprinting techniques will enable attribution for all pathogenic microorganisms related to food, and new chemical fingerprinting (metabolomics) will enable a significantly better understanding of the effect of chemicals in food. At the same time the new line of risk-based approaches will enable the setting of national -and international -targets for disease reduction, as well as provide the evidence base for such reduction efforts. These approaches will make their way into all parts of the global market, including the developing countries, which are likely to become more and more important agricultural producers and exporters. The introduction of a riskbased framework will enable developing countries to learn from mistakes (and successes) elsewhere. These countries have the potential to 'leap forward' into preventative systems focusing on risks. In addition, at a time where trade restrictions and national/regional protection of the agricultural production through heavy subsidies is likely to come to an end, it will be of paramount importance for the production sector also in developing countries to adapt to the new times. The benefits of improving food safety amount to a 'win-win' situation with improved national health as well as improved export potential. However, it will be crucial for these potential future developments that the developments in new food safety systems is clearly documented and communicated. Such communication has not yet commenced; national authorities as well as international organizations have an important future task in this area.

In supporting such developments, the WHO should focus on its core business. WHO is neither a funding agency nor an implementing agency like United Nations Children's Fund (UNICEF). Instead, it should aim to be the paramount knowledge organization in global health -gathering up the best technical, scientific, and practical information and making it accessible to all countries. This does not mean that WHO products must necessarily only be theoretical analyses aimed at scientific debate. A very significant amount of WHO documentation is directly applicable in national food safety efforts. The information material about GM food ('20 Questions on GM Food'), the exchange of national experience in risk mitigation activities through INFOSAN, or indeed the global spread of the simple WHO message on safe food handling ('Five Keys to Safer Food') all are clear testament to the fact that if the core remains sound science, the application of practical support to countries can take many forms.

WHO should continue to take bold action in support of continuous improvement of national and global food safety. This also means that WHO must remain an impartial and independent broker of sound science. Only thus can WHO contribute to a better -and safer -future for the world.

Public Health Measures: International Standards and Harmonization of Food Safety Legislation; Modern Approach to Food Safety Management: An Overview Further Reading Bloom BR (2011) WHO needs change

The Global Burden of Disease assessments -WHO is responsible?

Evolving public health approaches to the global challenge of foodborne infections

WHO (2010) Resolution WHA63.3 on food safety initiatives. Sixty-Third World Health Assembly