Republic of Uganda Ministry of Health THE MOH/WHO/FAO/FERG PILOT COUNTRY STUDY Presentation at the:...

Republic of Uganda Ministry of Health

THE MOH/WHO/FAO/FERG PILOT COUNTRY STUDY

Presentation at the:

High level Breakfast Meeting for the World Health Day Cerebrations

Theme: Food Safety for Good Health By:

Dr. Agaba Edson FridayFood Safety Coordinator National Drug Authority

7th April 2015

Imperial Royale, Kampala

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Date:

UGANDA /FAO/WHO /FERG INITIATIVE

THE NATIONAL BURDEN OF FOOD BORNE DISEASES

PILOT STUDY REPORT

March 2014

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Republic of Uganda

Ministry of Health

COVERAGE1. Background2. The Food borne Disease Burden Epidemiology Reference Group

(FERG)3. The Pilot Studies4. The objectives of individual country studies were to:5. Expected outputs of the study6. Methodology7. Results & Discussions8. Challenges 9. Conclusions 10.Recommendations11.Translating results of the food borne disease burden study into

policy and practice in Uganda.12.Way forward

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Backgrounda.Foodborne diseases are an important cause of morbidity and mortality worldwide

b.Foodborne diseases include all conditions that result from bacterial, viral, parasitic or chemical contamination of food.

c.The full extent of the burden and cost of unsafe food, however, is currently unknown.

d.To fill this data gap, the WHO Department of Food Safety and Zoonoses launched the Initiative to Estimate the Global Burden of Foodborne Diseases in 2006, in collaboration with multiple partners.

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The Food borne Disease Burden Epidemiology Reference Group (FERG)

a. The Food borne Disease Burden Epidemiology Reference Group (FERG) was established in 2007 by the World Health Organization (WHO) and coordinated by the WHO’s Department of Food Safety and Zoonoses (FOS).

b. The purpose of FERG is to estimate the global and regional burden of diseases commonly transmitted through food, develop protocols for burden of disease studies at country level, and facilitate the execution of such studies including food safety policy context mapping

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Backgroundd. The Initiative aims to:

• Provide estimates of the global burden of foodborne diseases by age, sex, and WHO region for a defined list of causative agents of microbial, parasitic, and chemical origin;

• Increase awareness and commitment among Member States for the implementation of Codex food safety standards;

• Encourage countries to use burden of foodborne disease estimates to develop food safety prevention, intervention and control measures and measure their effectiveness; and;

•Build capacity within countries to conduct burden of foodborne disease assessments and policy situation analyses as the basis for national, regional and international food safety policy.

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The Pilot Studies a.In 2010 a call was made by WHO for countries who were interested in participating in a pilot process for national burden of foodborne disease studies. Uganda, through the MOH, submitted her EOI on 15th September 2009 .

b.Countries which expressed interest were sent an overview of a national burden of foodborne disease study (from the FERG perspective), and a request for information relevant to the conduct of the study.

c.Following an assessment process undertaken by the WHO Department of Food Safety and Zoonoses (FOS), four countries were selected for pilot studies: Albania, Japan, Thailand, and Uganda. d.The Ugandan Pilot study was launched in Kampala. 6 – 7th March 2012

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The objectives of individual country studies were to: a.Deliver burden of disease estimates in the area of food borne diseases;

a.Contribute to burden of disease scientific and 'knowledge translation' capacity development within the country; and,

b.Provide results that are translated into food safety policy for the country involved.

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The anticipated uses of the results from the burden of food borne disease studies were:

a.Prioritisation of food safety as an issue within a country.

b. Prioritising of specific food safety issues within a country.

c. Provision of a baseline against which to evaluate future food safety interventions.

d. Assistance with harmonisation of international trade and regulatory standards.

e. Assessment of equivalence of food safety controls for import and export risk assessments (e.g. within the context of Codex Alimentarius).

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The country studies had two important parallel activities: a.The collection and analysis of data on the incidence of health effects caused by hazards in foods, so that the burden of disease can be aggregated into the disability adjusted health year (DALY) metric using calculation methodology developed by FERG; and, b. A situation analysis/context mapping exercise, followed by knowledge translation, which facilitates the use of burden information to develop food safety policy in a country.

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Expected Benefits of the Burden of Disease Study (BOD) to Uganda : 1.Enable the country to build capacity and establish more accurate baseline data on prevalence of food borne diseases in the country

2. Use the data to strengthen the national food control system that is evidence/science – based throughout tge entire food control infrastructure .i.e. from policy formulation to implementation including a food safety surveillance system. 3. Integration of data with the HMIS of the Ministry of Health;

4. Develop and implement a coordinated reporting and information sharing system; 5. Identification and response to outbreaks of food borne disease;

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Expected Benefits of the Burden of Disease Study (BOD) to Uganda : 6. Scale-up investigation and response to suspected food borne disease outbreaks. 7. Enforce the legal and regulatory framework using the International Health Regulations (IHR).

8. Address other food safety related issues including, but not limited to; gender, water supply, hygiene, sanitation and bioterrorism.

9. Protect our consumers from imported unsafe foods in light of previous global outbreaks of food borne diseases.

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Republic of UgandaMinistry of Health

Expected benefits to Uganda

10. Enable Uganda to identify existing data gaps. 11. Effectively address previous food safety concerns raised

by trading partners in food, for example the banning of Uganda Fish exports to the EU markets.

12. Ensure protection and promotion of our Tourism Industry. 13. Strengthen the national capacity to conduct future BOD and risk assessments; not only for food borne diseases but also for other diseases of major public health concern;

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14. The East African Community has initiated efforts to harmonize regional regulation of medicines and food safety under the Regional Codex activities, as key public health interventions.

A Protocol for the Establishment of the East African Medicines & Food Safety Commission and a draft regional Food Safety policy and Standards have been developed.

Results from the BOD assessment will guide these regional initiatives.

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15. Uganda is currently making efforts to strengthen its national food control systems for example, establishment of an overall Competent Authority for food Safety.

Results from this assessment shall enable Uganda to and translate the burden results into food safety policies, strategies, interventions and practices, and decisions from a more informed position.

16. Effective participation and formulation of country positions based on hard data’ especially during formulation of country positions in response to EAC, CODEX and WHO/ WHA guidelines, resolutions and recommendations.

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Process ( Methodology) 1a. Each pilot country was asked to assemble a team to conduct the

study. b. The members of this team included representatives from

government and academic institutions. c. Early in the process it was recommended that a situation analysis

be conducted according to the guidelines in the manual, to describe the regulatory and economic status of food safety in the country, identify actors, policies and practices, and generally provide context for the scientific data.

d. This analysis would also identify stakeholders who should be aware of the study, and who could contribute data and information

e. The initial step in the burden study was to identify hazards in the food supply that were relevant to the pilot country.

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Process ( Methodology) 2

a. Each pilot country was asked to assemble a team to conduct the study.

b. The members of this team included representatives from government and academic institutions.

c. Early in the process it was recommended that a situation analysis be conducted according to the guidelines in the manual, to describe the regulatory and economic status of food safety in the country, identify actors, policies and practices, and generally provide context for the scientific data.

d. This analysis would also identify stakeholders who should be aware of the study, and who could contribute data and information

e. The initial step in the burden study was to identify hazards in the food supply that were relevant to the pilot country.

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The National Pilot Study Teams were constituted as follows:

a. National Food Safety Advisory Committee

b. The National Technical Working Groups (NTWGS) or Task Teams

c. National Secretariat/Coordinating Office

d. WHO Technical Support Team

e. FAO Technical Support Team

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A. National Food Safety Advisory Committee

1.Dr. Jane. R. Aceng - DGHS /MOH ( Chairperson)2.Dr. Manyindo Ben - Deputy ED/UNBS/ former Deputy Chair to the Codex Alimentarius Commission – (Deputy Chairman)3. Prof. J.J. Otim - Presidential Advisor on Agriculture , Office of the President4. Dr. Anthony Mbonye - Commissioner Health Services(CH/MOH)5. Ms Hope Kabirisi - Special Presidential Assistant on Science & Technology6. Prof. J. Kakitahi - School of Health Sciences7. Prof. E. Sabiiti - Faculty of Agric. Makerere University8. Dr. Ssali William - Chairman, National Standards Council , UNBS9.Dr. E. Karyaija - Assistant Commissioner Diagnostics & Epidemiology, MIAAF 10.Dr. Samuel Mugasi - Coordinator, District Livelihood Support Programme,

MOLG 11. Ms Florence Adongo - Commissioner Water Quality, DWRM, Ministry of

Water & Environment 12.Prof. Nasinyama George - Veterinary Public Health /Makerere University , FERG TWG Member13.Dr. William Kyamuhangire - Food Science &Technology/ Makerere University14.Ms. Ruth Tugume – Research Officer, UNCS&T 15.Mr. Henry Kimera - CEO, Consumer Education Trust (CONSENT)16. Hotel & Catering Association - 1 Representative (to be identified)17. Uganda Manufacturers Association - 1 Representative (to be identified)

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TORs for the National Food Safety Advisory Committee

1.Vetting and selecting members of the NTF based on stakeholder representation, relevant experience in the area; food safety knowledge; potential situation analysis skills; educational background; realistic availability; gender; age; and sector of expertise (among others). The NTF may include members of the National Advisory Committee;

2. Provide policy, technical guidance, and oversight to the NTF and the study;

3. Review and approve work and documents produced by the NTF;

4.Based on the findings of the FERG BOD Study, provide political, policy, regulatory & technical guidance and direction to the Ministry of Health, on all matters related to food safety in Uganda and to the WHO; for comprehensive inputs to the wider policy-making processes within Uganda, the EAC region and globally.

5.The Minister of Health may, from time to time, refer to the Committee for consideration and advice on such questions as he or she may think fit, being questions relating to the Burden of Food borne diseases in Uganda.

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The National Technical Working Groups (NTWG). Six multi –sectoral and multi – disciplinary technical working groups/technical committees were formed as follows: a.Situation analysis working groupb.Enteric Diseases working groupc.Parasitic Diseases working groupd.Chemicals & Toxins Diseases working groupe.Source Attribution f.Coordination Secretariat

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B. National Taskforce Technical Working Group Members & Composition

INSTITUTION NAME POSITION

1 Ministry of Health 1.Dr. Issa Makumbi ACHS, Epidemiological Surveillance Division.

2. Dr. E. Mukoyo ACHS, Resource Centre,

3. Ms Caroline. K. Kafuko Senior Biostatistician, Resource Centre,

4. Dr. Kaboyo Winyi ACHS, Veterinary Public Health

5. Dr. Julius Lutwama Head, Department of Arbovirology and Emerging Viral Infections, UVRI

6. Mr. Guma Gaspard Head, Central Public Health Reference Laboratory Services

7. Mr. Mulabya F. SPHI, Environmental Health Division

8. MR. D. Namanya Geographer, EHD/Planning Dept.

9. Dr. Agaba E. F Food Safety Coordinator, National Drug Authority

10. Ms. Irene Wanyenya Deputy Food Safety Coordinator, NDA

11. Ms Mary Tumushabe Secretary Food Safety, NDA

2 Ministry of Agriculture Animal Industry & Fisheries

3 Officials (Animal, Crop, Fisheries)

To be nominated by the PS/MAAIF

3 Ministry of Water & Environment

Ms. Adongo Florence Commissioner Water Quality, DWRM

4 MOLG Director Health Services KCCA, Health Dept

5 MGL&SD Commissioner Occupational Safety & Health Dept.

6 Min. Tourism 1 Vet. Uganda Wildlife Authority (UWA)

7 Uganda Bureau of Statistics (UBOS)

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8 Uganda National Bureau of Standards (UNBS)

Mr. David Eboku Food Standards

9 Directorate of Government Analytical Laboratories

Mr. Geoffrey .Onen Principal Government Analyst

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National Taskforce Technical Working Group Members & Composition (2)

10 Makerere University, Veterinary Public Health

Prof. Nasinyama FERG Member, Deputy Director Research & Publications

11 Makerere University, School of Public Health

Dr. Roy Mayega

12 Makerere University Chemistry Dept.

Prof. B. T. Kiremire

Chemistry Department,

13 Makerere University, School of Technology, Nutrition & Bio – Engineering

Prof.. Archileo N. Kaaya

Dr. Charles Muyanja

14 WHO, Uganda Mr. Collins Mwesigye

15 FAO, Uganda 1

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* It was important that members of the Task Force needed to possess not only skills in or knowledge of the country’s food-safety

context, but also the abilities and time to perform, manage and/or review these analyses

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TORs for the National Taskforces

1.Coordinate and/or undertake all analyses (Stakeholder, Political context and National policy processes, data collection & analysis.2.Commission the work where appropriate, including hiring of Consultants or other experts3.Promote the involvement of key stakeholders, 4.Oversee the production of the final outputs:

• a peer-reviewed document analyzing the actors, context and dynamics of food safety within their particular country, how this has changed over time, and what prospects the future holds.

• This will also assess which stakeholders, structures and processes may support or impede changes towards evidence-informed policy and practice in food safety at the national level.

• a national-level strategy positioning foodborne disease-burden data as a comprehensive input into national policy-making. (e.g. cabinet recommendations, evidence-informed policy brief and deliberative dialogue to an op-ed piece.

• synthesis documents reflecting the Task Force’s work in each of the three analyses.• evaluative reports reflecting experience, data and recommendations arising from the conduct of

these situation analyses to better assist the programme’s eventual scale up across all WHO regions.

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F. National Secretariat/Coordinating Office: NDA Food Safety Dept.

1.Dr. Agaba. E. Friday - Principal InvestigatorHead Food Safety Dept.

2. Ms. Irene Wanyenya - Deputy Food Safety Coordinator

3.Ms Mary Tumushabe – Office Administrator

TORS• Act as the link between the MOH, FSAC, NTF and WHO/ FAO/FERG Teams;• Provide regular communication with FERG;• Coordinate development of the BOD Study work plan;• Coordinate implementation of the work plan and related BOD activities in Uganda;• Receive all BOD study working documents and ensure that they are circulated to Team

members in time;• Act as a channel for the exchange of information between participating stakeholders.

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F.WHO Technical Support Team

1. Dr. Rob Lake2. Ms. T. Kuchenmuller3. Ms Amy Louise Cawthorne

F.FAO Technical support Team1. Ms. Mary Kenny2. Ms. Rezaei, Maryam 3. Mr. Jean Kamanzi4. Ms. Valerie Davidson

G.Funding• NDA• FAO• WHO

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Scope of Food borne Disease /illness coverage

a. The study in Uganda covered the whole range of pathogens/hazards that are common in the country. b. All the three categories are of equal public health importance in Uganda; however, the following ranking according to priority shall be used.

• Pathogens• Chemicals and toxins• Parasites

c. The study shall follow the Food Chain Approach, i.e. from production (farm) to management of food waste (disposal)

d. The following are the pathogens/hazards, including the selection criteria, that we consider most important for Uganda.(Ref: WHO BOD Questionnaire,

Uganda)

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1. Parasites

Parasites

No.

Yes No Do not know

Reason for response

X

Common cause of diarrheal disease in Uganda especially children

1 Giardia duodenalis

X

2 Entamoeba histolytica

X

3 Cryptosporidium spp.

4 Fasciola hepatica X Common in domestic animals

5 Fasciola gigantica

X

6 Echinococcus multilocularis

X

7 Echinococcus granulosus

X

8 Taenia solium and cysticercosis

X

9 Trichinella spiralis

10 Anisakis spp.

11 Toxoplasma gondii

12 Clonorchis sinensis

13 Opisthorchis felineus

X Common helminthes in Uganda in all age groups

14 Ascaris lumbricoides

Other?

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1. Enteric pathogens

Enteric pathogens

No. Yes No Do not know

Reason for response

Bacterial toxin Staphylococcus aureus

1 X X

2 Bacterial toxin Clostridium perfringens

3 Bacterial toxin Bacillus cereus X

X High prevalence Zoonosis in Cattle keeping communities

4 Brucella sp.

Research on – going at Mbarara University of Science & Technology

X

Common in Uganda Research on – going at the Department of Veterinary Public Health, Makerere University Ranked as a food borne disease of public health importance in the East African Region during the Regional FAO/WHO/KEMRI Research meeting on improving food safety in the meat value - chain ; Nairobi, Kenya: 26 – 28 August 2011

5 Campylobacter sp.

Potential risk from packaged foods

6 Clostridium botulinum X

Ranked as a food borne disease of public health importance in the East African Region during the Regional FAO/WHO/KEMRI meeting on improving food safety in the meat value - chain ; Nairobi, Kenya: 26 – 28 August 2011

7 Enteroaggregative E. coli (EaggEC) X

8 Entero-pathogenic E. coli (EPEC) X


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Enteric pathogens 2

9 Entero-toxigenic E. coli (ETEC) X

Ranked as a food borne disease of public health importance in the East African Region during the Regional FAO/WHO/KEMRI Research meeting on improving food safety in the meat value - chain ; Nairobi, Kenya: 26 – 28 August 2011

10 Helicobacter pylori X

11 Hepatitis A virus X

Currently a big public health problem in districts of Soroti, Kitgum and Katakwi (2007 – 2008) in Northern Uganda. This outbreak also resulted from El Nino floods.

12 Hepatitis E virus X

13 Listeria monocytogenes X

High prevalence Zoonosis in Cattle keeping communities

14 Mycobacterium bovis X

15 Non-cholera Vibrio spp.

16 Norovirus

17 Prions

18 Rotavirus

Ranked as a food borne disease of public health importance in the East African Region during the Regional FAO/WHO/KEMRI research meeting on improving food safety in the meat value - chain ; Nairobi, Kenya: 26 – 28 August 2011

19 Salmonella (non-typhoidal) sp. X

Prevalent in Uganda

20 Salmonella typhi X


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Enteric pathogens 3

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Shiga-toxin producing E. coli (STEC) X

Common cause of diarrheal disease in Uganda.

22 Shigella sp. X

Frequent outbreaks and endemic in some parts of the country especially association with the Elnino weather patterns of 1997 -2000

23 Vibrio cholerae O1/O139 X

24 Yersinia sp.

Other? Anthrax

Frequent outbreaks of human anthrax have occurred in Uganda due to consumption of meat from infected animal carcasses from the Queen Elizabeth National Park, Kasese and Bushenyi districts (2008 – 2009

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1. Chemical agents and toxins

Chemical agents and toxins

No. Yes No Do not know

Reason for response

1 Lead

X Previous studies in Uganda revealed high residue levels for plants grown in urban wetlands

2 Methylmercury X

Previous studies in Uganda revealed high residue levels for plants grown in urban wetlands

3 Aristolochic acid

4 Cadmium X


5 Pesticides

X

Abuse of pesticides by farmers. Use of sub – standard or banned pesticides. For example, between 1991 and 2003, Socio – economic Impact of the ban on fish exports Uganda suffered fish export bans to the EU markets due to food safety related concerns of salmonella, cholera disease outbreaks and suspected fish poisoning by unscrupulous fishermen with an agro– chemical, endosulfan.

6 (Shell)fish toxins

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Chemical agents and toxins 3

7 Mycotoxins

X

On- going studies conducted in the country the Dept. of Food Science & Technology , Makerere University indicate that aflatoxin contamination levels of some agricultural produce (coffee, maize, groundnuts) are above the FDA/WHO recommended limit of 20ppb.

8 Melamine Potential threat from imported food X

9 Cyanide in cassava X

10 Peanut allergen

11 Arsenic X


12 Dioxin

X

Studies under the NEMA/ UNEP/SAICM(Strategic Approach to International Management of Chemicals) Project has identified both intended and un – intentional POPs including Dioxins occur in our environment ecosystems

Other? Methanol Poisoning Cases of poisoning and deaths have occurred in different parts of Uganda following consumption of packaged local drinks especially alcoholic beverages found to be contaminated with Methanol (2007, 2009/2010).

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ORGANIZATIONAL PROCESSES

A. Key Stakeholders (sources of data and existing capacities)

1.MOH – NDA, CH, ESD, HMIS, VPH, UVRI/CDC, CPHL, EHD, PA Unit, FSAC Hospitals/Health facilities2.MAAIF - Animal Health , Fisheries, Crop Protection.3.MW&E - DWRM, NW&SC, NEMA4.MOLG – District Health Department, Local & Urban Health

Authorities (KCCA)5.MGL&SD - Occupational Safety & Health Department.6.MoFED - Uganda Bureau of Statistics, Uganda National Council

of Science & Technology 7.MTI&C - Uganda National Bureau of Standards, National Codex

Committee8.M Tourism - Uganda Wildlife Authority9.MIA - Directorate of Analytical Laboratories (Forensic &

Diagnostic)10.Research & Academia – VPH/MAK, Chemistry/MAK, FS&T/MAK, IPH, UIRI, Kyambogo University11.Food Processing Industry - Uganda Manufacturers Association12.Food Houses - Uganda Hotel Owners Association 13.Consumer Organization - Uganda Consumer Education Trust ( CONSENT)

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C. Uganda’s Laboratory capacity to identify food – borne diseases.

1.Regional Referral Hospital laboratories and hospital based laboratories to confirm diagnosis

2. Microbial – CPHL, Hospital Labs, IPH, VPH/MAK, UVRI, FS&T

3. Parasitic - CPHL, Hospital Labs, IPH, VPH/MAK, UVRI, FS&T

4. Chemical - DGAL, Chemistry/ MAK, UNBS, DWRM(MW&E), NW&SC,UIRI, FS&T

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B. What type of data was available in Uganda

1. HMIS/MOH – National disease prevalence/incidences, including FBDs, Resource Centre, the Central

HMIS data base and the IDSR system at the Ministry of Health Hqts. 2. UBOS – Demographic& Health surveys (UDHS), National Household

surveys & National Census data3. DF&T/MAK - Mycotoxin contamination, National Food Consumption

data, chemical residues in food4. MAAIF – Crop diseases , zoonotic diseases in domestic & wildlife

animals, fish diseases & Chemical residues5. UWA – Zoonotic diseases in Wildlife ( National Parks & Reserves)6. VPH/MAK – Food borne diseases e.g. Campylobacter in chicken7. DWRD, NEMA, NW&SC – Chemical residues in water and other ecosystems8. UNBS, NCC - Food Standards9. MOLG (KCCA) – District prevalence/incidences of FBDs10. MGL&SD (OH&S Dept. ) - Pesticide poisoning11. Research& Academia - Prevalence/Incidence of FBDs

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FINDINGS(Hand out)

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RESULTS & DISCUSSIONS

The study teams noted the following: 1.There were some barriers to DALY calculations from data gaps in the information available. An important one is the lack of etiology information for the large number of reported acute diarrhoea or categorized as “intestinal worms” or “worm cases each year. 2. The dataset which appeared to be most complete was that for aflatoxins – there was some data on the incidence of HCC, as well as reasonable amount of information on contamination and food consumption.

3. From the available data, a good qualitative case could be made to address brucellosis and aflatoxins (as a cause of stunting) as priority food safety issues for which there is reasonable evidence of both food contamination and incidence of disease. The major data gap was the etiology of acute diarrhoeal illness, as well as community level estimates of incidence.

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RESULTS & DISCUSSIONS

4. It was important that waterborne and food borne diseases are included in the report, but it was not easy to identify more clearly diseases which are likely to be mostly food borne, and those which are mostly waterborne. However it was noted that most water sources for consumption are contaminated with microbes

5. It was difficult to generate DALY estimates from the available data – particularly due to the shortage of community level incidence data.

6. This report, with some refinement (especially a data gaps analysis) could serve as an output of the study for the Ugandan stakeholders, and to create knowledge translation vehicles (issue briefs) for decision makers from this material.

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Application of the Multi-Criteria Decision Analysis (MCDA) Tool Formal analysis and integration of information using Multiple Criteria Decision Analysis (MDCA). MCDA is an approach developed to deal with problems characterized by:

a. Multiple optionsb. Multiple criteriac. Potentially many stakeholdersd. Need to justify selectionse. Need for transparency/auditability of decision

Examples:• Public Health impact • Market-level impacts• Food security• Social factors

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Application of the FAO MCDA Tool

Comparing more than two or three criteria across multiple options is difficult without formal MCDA methods because:

• Methods support the decision-making process – do not replace the decision maker• MCDA methods promote systematic thinking through:

definition of issues or alternatives identification of criteria impact with respect to various stakeholders

This challenge was addressed by application of The Multi-Criteria Decision Analysis Tool (MCDA) For Evidence-Informed Decision Making For Food Safety Issues. This tool enables:

1.Focussing on more than two or three criteria is difficult without support such as use of the MCDA tool.2.The MCDA tool does not produce decisions or provide the solution as a revealed truth but it supports the decision making process by helping to deal with the information

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Application of the FAO MCDA Tool

1.MCDA promotes systematic thinking through:• definition of options • identification of criteria• impact with respect to various stakeholders

2.Identifies conflicts and helps in the understanding of conflicts and tradeoffs 3.A transparent decision tool4.The integration of stakeholders is supported. Negotiations among stakeholders can be facilitated.5.Subjectivity is made explicit

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Application of the Multi-Criteria Decision Analysis (MCDA) Tool

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It is a useful Multi-factorial Risk Prioritization Framework for Foodborne illnesses

a.Encourages multi-disciplinary and multi-stakeholder inputsb.Highlights the fact that there are a range of players who have input to food safety decision making, have data and information, c.Inputs Cross-ministerial discussion and input required – key line ministries (health and agriculture), but also environment, finance, food security. d.There is need to bear in mind these many different inter-related goals, and the diversity and range of persons and institutions who can and should influence either through opinion, data, information etc.

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Challenges (1)1.Most of the national data at the Resource Centre and hospital is aggregated (0-5 yrs and above 5yrs) and not stratified by age groups as required in the FERG tool.

2. A lot of data, mainly raw data, is with stakeholder departments and is not available or shared with other relevant stakeholder departments.

3. Differentiation of the parasites by species is not done when data is aggregated and reported from the districts through the HMIS in, MOH. Reports indicate “intestinal worms” or simply “worms” and not specific species of the parasite or worm.

4. Mortality data due to a number of parasites especially worms is hard to obtain since deaths are usually not attributed to worm infestation and sequelea may not be linked to the initial parasitic infection.

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Challenges (2)

5. There is inadequate laboratory capacity and poorly developed infrastructure to diagnose some parasites e.g. Trichinella spiralis, Toxoplasma gondii, etc at meat inspection and in the hospital laboratories.

6. The disease reporting system is not standardized between different reporting institutions, laboratories or abattoirs.

7.Paper based/manual data management as opposed to electronic data storage and retrieval system is still being used in many places leading to delays, in data retrieval and analysis, incomplete data due to loss of records.

8. Syndromic diagnoses (e.g. acute diarrhoea) are at times recorded without mentioning the etiologic agent making it difficult to discern the etiologic agent causing the illness because this could be due to parasitic hazards (e.g. amoebiasis) or bacteria (e.g. shigellosis).

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Challenges (3)

9.Food safety decisions such as national policy requirements and resource allocations should be based on clear evidence for a broad range of risks that are created by foodborne hazards. 10. While the burden of foodborne illness is clearly important, other risk factors, such as impact on trade, impact on food security, cannot be neglected in making food safety decisions.

11. The appropriate set of risk factors is determined by an individual country based on its needs and issues. By considering a broad set of factors, the national policy base is better informed and decisions are not driven by a single consideration (e.g. supporting export market for a particular commodity).

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Conclusions

Arising from the study and key findings outlined, the following are the conclusions: a.Groundwater from deep boreholes and treated final water from Gaba water works are safe for drinking with respect to bacteriological quality. Protected springs are unsatisfactory in terms of bacteriological quality rendering them unsafe. b. In terms of safety of drinking water with respect to persistent chemical quality, all water drinking sources have low concentrations below the recommended national drinking water standard and WHO guidelines.

c. The major sources of chemical pollution are industries in the catchment imported chemicals, electronics, and the contaminated sediments that have accumulated over time in the bay. Analysis of previous secondary and primary data from scientific studies showed that there is significant increase in quantities of pollution entering the bay from its catchment with long-term detrimental social, economic and environmental risks.

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Conclusions (2)

d. The cumulative presence of persistent toxic inorganic chemical pollution levels within the inner Murchison bay is significant in sediments, algae and fish with quantities much higher than the recommended WHO guideline values posing high long-term health and environmental risks. e.Increased awareness levels on existing pollution threats and possible drinking water safety challenges exist among stakeholders.

f.However, there is weak enforcement of laws, weak political support and unwillingness of opinion leaders in communities, to address quality of drinking water. f. There is inadequate communication, information sharing and education to public on status of quality of drinking water they use, pollution threats and the implications.

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Recommendations

The study identified key areas for further work and research required, as follows:

a. Generally there were major data gaps and weaknesses on documented foodborne diseases in Uganda.

b. More research is needed to collect, synthesize this data at all level of delivery of healthcare services.

c. A study to analyse diarrhoeal faecal samples from Uganda, to attempt to fill this data gap and un- package the common clinical diagnosis of diarrhoeal disease or categorised as “intestinal worms” or “worms to more specific aetiological diagnosis.

d. Specific inclusion of food borne diseases into the HMIS Database of MOH, the MAAIF/ VPH Diseases surveillance Data base and that of other research institutions e.g. School of Public Health, UVRI,

e. Strengthen and harmonizing sharing of food borne disease data and reports by those in d, above.

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Recommendations (2)e.More research work on national Food Consumption studies and Source Attribution which are important inputs for Exposure assessments (Risk Assessment).

f. Adopt and use the MCDA Tool for decision making on food borne problems.

g. At national level, develop Pathogen specific community level incidence estimates for enteric diseases to support more BOD work in future.

h. This report, with some refinement (especially a data gaps analysis) could serve as an output of the study for the Ugandan stakeholders.

i. It would also be used and interesting to create knowledge translation vehicles (issue briefs) for decision makers from this material.

j. There is need to find a way to publish the results in the scientific literature.

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Translating results of the food borne disease burden study into policy and practice in Uganda.

Uganda already identified means of increasing utilization of the research findings resulting from the national burden of disease assessment in food safety policies and practices. Findings shall, among others:

A.Policy frame work

1.An advocacy tool to all stakeholders on the magnitude of food borne diseases in Uganda; their contribution to the overall national burden of disease (BOD) and their negative impacts to national socio – economic development.

2. The study findings shall enable the country scale –up the on – going efforts to strengthen its national food control systems and establishing harmonised policies, legal and institutional framework.

3. Greatly contribute to decision making, formulation or shifts in various health policies, strategies, programmes and interventions.

4. Justification for development, reviewing, updating, harmonization of Food Safety legislation and regulation and standards, based on science and hard data.

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Republic of Uganda

Ministry of Health

Translating results of the food borne disease burden study into policy and practice in Uganda.

6.Implementation of cost - effective Food Safety analyses, plans and interventions.

7. Strengthen regional and global collaboration in food safety issues.

8. Use of results to lobby for increased resource allocation for food safety activities at all levels of government

9. Assessing the contribution of food borne diseases to the overall national burden of disease including quantifying the disease burden in socio – economic terms.

10. Promote Public Private Partnerships in food safety

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B. Institutional Capacity & Linkages

1.Strengthening FS Institutional capacity, synergies , linkages, coordination and accountability.

2. The BOD data shall provide the benchmarks for establishing an efficient, effective, coordinated and integrated national food control system for consumer protection and fair trade in food . 3. Provide baseline data for updating the Food Safety data and Disease Surveillance systems, and in particular, management of food safety related diseases and ill health, incidences and forecasting;

4. Implementation of an integrated Food Safety information management system and information sharing between the various key stakeholders 5. Use of preventative approaches in management of food safety along the food chain

6. Promote science based food safety initiatives and interventions including aassessment of the cost – effectiveness of such interventions;

7. Act as benchmarks for monitoring and evaluation of food safety measures;

8. Mainstreaming food safety in special health programmes targeting the most vulnerable people, e.g. HIV/AIDS, hospital patients, maternal & child health, the elderly, displaced persons, and school feeding programmes.

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C.Food Trade & Consumer protection

1.Scaling – up Consumer advocacy, sensitization and awareness for improved consumer choice and self – policing. 2. Support to the private sector to comply with the set standards; especially the food processors, hotel & catering sectors and the street/highway food vendors. 3. Improve Uganda’s competitiveness in the domestic and international Food trade; and in the hotel & tourism sectors, among others.

4. Ensure that food consumed on the domestic market ( both locally produced and imported food ) meet the set national and international standards .

6. Ensure Uganda’s food exports satisfy international standards for food safety and quality and Uganda’s food competes favourably at national and global food markets

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Way forward

1.Study finalized and report ready for binding2.For endorsement by the Hon.MOH3.Official launch for July/August 20144.Need to develop proposals in line with the recommendations, for possible funding for example:

a. FAO - on use /role of MCDAs in Food safety decision – making.

b. IAEA - Nuclear applications in food safety laboratory

analysis.

c. WHO/FAO - Proposed Project to Strengthen an Integrated National Food Safety & Control System in Uganda.

d. EU - Proposed Project to Strengthen An Integrated National Food Safety & Control System In Uganda

e. AU –IBAR - Analyse food-chain surveillance systems and rapid alert networks in eastern Africa.

- Partnership for Aflatoxin Control in Africa(PACA) - Funding under the proposed establishment of

Food Safety Authority at African Union and of a Rapid Alert System for Food and Feed -RASFF.

1. 1. 2.

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I THANK YOU

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Republic of Uganda Ministry of Health THE MOH/WHO/FAO/FERG PILOT COUNTRY STUDY Presentation at the:...

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