Prevalence of Foodborne Diseases in South East Asia

Ratih Dewanti-Hariyadi, Department of Food Science and Technology and South East Asia Food and Agricultural Science and
Technology (SEAFAST) Center, IPB University, Bogor, Indonesia
© 2023 Elsevier Inc. All rights reserved.
This is an update of R. Dewanti-Hariyadi, D Gitapratiwi, Foodborne Diseases: Prevalence of Foodborne Diseases in South East and Central Asia,
Editor(s): Yasmine Motarjemi, Encyclopedia of Food Safety, Academic Press, 2014, Pages 287–294, ISBN 9780123786135, https://doi.org/10.1016/
B978-0-12-378612-8.00075-5 (https://www.sciencedirect.com/science/article/pii/B9780123786128000755).

Introduction 1
Brunei Darussalam 2
Cambodia 2
Indonesia 3
Laos 4
Malaysia 4
Myanmar 5
Philippines 6
Singapore 6
Thailand 7
Vietnam 7
Conclusions 9
References 9

Key Points
• Countries of South East Asia belong to either the WHO Southeast Asia Region or the WHO Western Pacific Region.
• Foodborne disease outbreaks in countries of South East Asia are described, including the likely etiological agents,
incriminated foods and possible behaviors contributing to the outbreaks when known.

Abstract

Foodborne diseases in the South East Asia are thought to impose one of the highest public health burdens of any region of
the world. Bacillus cereus, Campylobacter, pathogenic Escherichia coli, Salmonella spp., Staphylococcus aureus, Vibrio cholerae
remain the predominant bacterial pathogens associated with diarrheal diseases and frequently isolated from various foods.
In addition, protozoan and helminth parasites are still major concern in certain area especially in association with raw fresh
water fish consumption. Water is a common vehicle for foodborne disease through its uses for drinking, washing and fresh
water fish farming. Meanwhile schools are common places for many outbreaks to occur. Collaborative efforts of each country
in the region with various parties have been established and various programs have been developed in order to reduce
instances of foodborne disease outbreaks. The final goal is to achieve the Sustainable Development Goals (SDGs) especially
related to zero hunger, good health and well-being, and water and sanitation. A 5-year evaluation (2014–2019) of countries
of the Association of South East Asian Countries (ASEAN) has resulted in a framework for action on food safety in the WHO
South East Asia Region to reach the regional food safety goal.

Introduction

Geographically, South East Asia (SEA) consists of Brunei Darussalam, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines,
Singapore, Thailand, Timor-Leste and Vietnam. However, these countries are divided between two Regions of the World Health
Organization (WHO) where the WHO Southeast Asia Region includes Indonesia, Myanmar, Thailand and Timor-Leste, while
the WHO Western Pacific Region includes Brunei Darussalam, Cambodia, Laos, Malaysia, Philippines, Singapore, and Vietnam.
Food- and waterborne diarrheal diseases are the leading causes of illness and death, particularly in less developed countries.
WHO estimated that the burden of foodborne disease (FBD) is comparable with that caused by malaria, HIV/AIDS, or tuberculosis
(Havelaar et al., 2015). Of the 600 million foodborne illnesses annually worldwide, 150 million occurred in South East Asia region.
Meanwhile, the economic impact of FBD in low- and middle-income countries in Asia was estimated to be not less than US$ 63.1
billion in 2016.

Reference Module in Food Sciences https://doi.org/10.1016/B978-0-12-822521-9.00071-X 1

Foodborne diseases in SEA are still dominated by diarrheal diseases associated with Salmonella, Bacillus cereus, Staphylococcus
aureus, Vibrio cholerae and pathogenic or diarrhoeagenic Escherichia coli. These types of pathogens have not changed much over
the years (Dewanti-Hariyadi and Gitapratiwi, 2014). Nonetheless, consideration should be given to the reality that surveillance
of foodborne pathogens often is limited to the conventional pathogens and rarely include newly recognized pathogens, such as
Enterohaemorrhagic Escherichia coli, Listeria monocytogenes, and Norovirus. Salmonella spp. are isolated in various foods in Cambo-
dia, Indonesia, Laos, Malaysia, Philippines, Thailand, Singapore and Vietnam. Bacillus cereus is considered an important pathogenic
bacterium associated with outbreaks in Indonesia, Malaysia and Thailand as described below. Meanwhile, Staphylococcus aureus,
which is also generally associated with poor personal hygiene, is reported involved in outbreaks in Cambodia, Indonesia, Malaysia,
Thailand and Vietnam. Seafoods and/or water are often associated with Vibrio parahaemolyticus and Vibrio cholerae, respectively, and
both pathogens have been isolated from foods and/or outbreaks in Brunei, Indonesia, Malaysia, Myanmar and Thailand.
Protozoa and parasites which still cause foodborne diseases indicate inadequate hygiene and food preparation practices.
Protozoa and parasites were detected in vegetables in Indonesia and Thailand as well as fresh water fish in Myanmar. Biotoxins
are less commonly reported although ciguatera poisonings caused by consumption of tropical and subtropical reef fishes have
occurred. These are produced by the dinoflagellates Gambierdiscus species. Ciguatera can cause severe acute illness and prolonged
neurological symptoms. An extensive journal and internet review suggested that poisonings have occurred in few countries, such
as Singapore, due to imported mackerel (1 case in 2006), Malaysia (two events involving 26 and 22 people in 2010) and Philip-
pines (38 cases between 1995 and 2004) (Chan, 2015).
Water is a common vehicle of the foodborne disease outbreaks, whether via drinking, washing or fresh water fish farming.
Reports of water-related outbreaks are recorded in Indonesia, Laos, Malaysia, Myanmar, the Philippines and Vietnam. Vibrio chol-
erae, Salmonella typhi, Campylobacter jejuni, pathogenic Escherichia coli, rotavirus and protozoan parasites have been epidemiologically
linked to water-related outbreaks.
Meanwhile, schools are often the site for foodborne disease and/or food poisoning outbreaks in the region. Several outbreaks in
school were reported in Cambodia, Indonesia, Malaysia and Philippines. Various foods, such as cold beverages, rice meals and
breads, were suspected or confirmed as the vehicles of the outbreaks. Salmonella Enteritidis, Salmonella typhi and Staphylococcus
aureus were among the group of bacterial pathogens involved in the school-related outbreaks.
The following sections will describe some of the more recent precedent pertaining foodborne diseases and food safety in specific
countries.

Brunei Darussalam
There has not been a major foodborne disease outbreak reported in Brunei since 1999. Recently, however, there has been an increase
in gastroenteritis (diarrhea and vomiting) cases in Brunei. In 2022, a total of 727 cases of gastroenteritis have been reported with
a majority of the cases in children of 5 years old and below, which is a significant increase from the 605 reported cases in 2021 (Kon,
2022).
A survey of Vibrio parahaemolyticus in 23 randomly selected seafood samples purchased in Brunei between January and April
2013 concluded that none of the samples were contaminated with the bacterial pathogens (Murang et al., 2014). The study included
11 samples from wet markets and 12 from supermarkets where the analysis was carried out using Most Probable Num-
berdPolymerase Chain Reaction (PCR) method.

Cambodia

Diarrhea among children is the predominant disease burden in Cambodia. Between 2010 and 2015, as many as 146 out of 288
disease outbreaks in the country was linked to diarrhea or directly to a foodborne disease (Lawpoolsri et al., 2018). In 2019, the
Mekong Institute reported that between the years 2014 and 2019, there were 134 foodborne disease outbreaks with 5825 cases,
5598 hospitalizations and 81 deaths. Thompson et al. (2021) presented 15 foodborne outbreaks that occurred between 2015
and 2020 involving various foods and four of them (26.7%) were school-related. While investigation of the outbreaks concluded
that no known causative agents could be determined in 9 (60%) of the outbreaks, Salmonella typhi, Trichinella and methanol were
the etiological agents linked to the six confirmed outbreaks.
A study to determine the prevalence of Salmonella spp. and S. aureus in chicken meat and pork in Cambodia markets was reported
by Rortana et al. (2021). A total of 532 samples were obtained from 52 traditional markets and 6 supermarkets in 25 provinces of
Cambodia between October 2018 and August 2019. The samples include chicken meat (n ¼ 204), pork (n ¼ 204), chicken cutting
board swabs (n ¼ 62) and pork cutting board swabs (n ¼ 62). The overall prevalence of Salmonella spp. and S. aureus were 42.1%
(224/532) and 29.1% (155/532), respectively, with 14.7% (78/532) of the samples containing both bacteria. The prevalence of
Salmonella spp. was 42.6% in chicken meat, 41.9% on chicken cutting boards, 45.1% in pork and 30.6% in the pork cutting board.
Chicken meat had a significantly (p-value < 0.05) higher prevalence of S. aureus (38.2%) than chicken cutting board (17.7%), pork
(28.9%) and pork cutting board (11.3%.) The mean average of Salmonella in chicken meat was 10.6 MPN/g and in pork samples
11.1 MPN/g. Meanwhile, the average number of coagulase positive Staphylococci in chicken and pork samples were 2.6 and 2.5 Log
CFU/g, respectively.
 Prevalence of Foodborne Diseases in South East Asia 3

Evaluation of blood stream infection yielded several foodborne pathogens. Of the 445 clinical isolates obtained from 5714
blood samples of 4833 hospitalized patients showed that the most commonly isolated bacterial pathogen was Escherichia coli
(n ¼ 132; 29.7%). Other pathogens isolated were Salmonella spp. (n ¼ 64; 14.4%), Burkholderia pseudomallei (n ¼ 56; 12.6%)
and Staphylococcus aureus (n ¼ 53; 11.9%). Ten out of 46 (21.7%) of S. aureus isolates showed methicillin resistance and four
were also resistant to erythromycin, clindamycin, moxifloxacin and sulfamethoxazole-trimethoprim (SMX-TMP). Eighty-one
E. coli isolates exhibit combined resistance to amoxicillin, SMX-TMP and ciprofloxacin (62.3%) and 62 isolates (47.7%) were
confirmed to produce extended spectrum beta-lactamase. Salmonella isolated from the blood specimens showed high rates of multi-
drug resistance (71.2%) and high rates of decreased susceptibility to ciprofloxacin (90.0%) was observed in Salmonella typhi. In
addition, resistance to carbapenem was observed in 5.0% of 20 Acinetobacter sp. isolates (Vlieghe et al., 2013).

Indonesia

The event-based foodborne disease surveillance in Indonesia was carried out by two agencies. In 2019 the Ministry of Health re-
ported 133 foodborne diseases outbreaks from 31 provinces involving 5958 cases with Case Fatality Rate (CFR) of 0.43%. No
known etiology or specific food vehicle was reported. Meanwhile, the National Agency from Drug and Food Control (NADFC) re-
ported 77 foodborne disease outbreaks from 21 provinces in 2019 (NAFDAC, 2019). Forty outbreaks were suspected to be linked
epidemiologically to microbial pathogens with Staphylococcus aureus confirmed in 3 outbreaks, while Bacillus cereus and Salmonella
was linked to 1 outbreak each. However, reports from both agencies showed similarity in terms of the origin of the foods involved in
the outbreaks. According to the data from the Ministry of Health, foods from households were most commonly associated with
outbreaks with percentages of 44%, 25%, and 31% for 2019, 2020 and 2021, respectively. The NADFC reports in 2019 and
2020 also suggested that foods from households accounted for 40% and 49% of the outbreaks, respectively. The origin of the
food that causes poisoning and the percentage has not changed much from the previous decade (Dewanti-Hariyadi and Gitapratiwi,
2014).
Before 2005, the prevalence and pathogens associated with diarrhea were reported during a 24-months surveillance study (Agtini
et al., 2005). Infants had the highest incidences of diarrhea (759/1000/year) and cholera (4/1000/year). Meanwhile, children aged
1–2 years had the highest incidence of shigellosis (32/1000/year). Shigella flexneri was the most common Shigella species isolated
and 73%–95% of these isolates were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol and tetracycline but
remain susceptible to nalidixic acid, ciprofloxacin, and ceftriaxone. The author also reported that cholera was the most common
disease among children, with an overall incidence of cholera of 0.5/1000/year. Of the Vibrio cholerae O1 isolates, 89 (58%) were
El Tor Ogawa and 65 (42%) were El Tor Inaba serotype. Thirty-four percent of patients with cholera were intravenously rehydrated
and 22% required hospitalization.
A more recent picture on foodborne pathogens in Indonesia was a systematic review based on 1.176 published and unpublished
foodborne disease outbreaks occurring between 2000 and 2015. The review suggests that pathogenic Escherichia coli was the most
common foodborne pathogen associated with the outbreaks (20%), followed by Bacillus cereus (19.4%), Staphylococcus aureus
(18.3%) and Salmonella (4.6%). Similar to the report of Ministry of Health and the NADFC, the review also reported home-
made foods (46.9%) as the most common vehicle in all of the outbreaks (Arisanti et al., 2018). A study of elementary school
students stools in 4th and 5th grades in Surabaya (n ¼ 218) showed that 6.88% of the stool samples contained diarrheagenic Escher-
ichia coli (DEC) while 6 samples (0.4%) had E. coli O157:H7 (Syahrul et al., 2018). The study also suggested that school foods
should be considered as at high risk for causing bacterial infection, particularly cold beverages, foods with peanut or other sauces,
and meatball sauces. Unhygienic practices can lead to the presence of indicator bacteria, such as coliform and/or E. coli in foods.
E. coli was also isolated from 73% of samples of dangke, an Indonesian traditional fresh cheese made from cow’s milk (Hatta
et al., 2013)
Until recently foods contamination by V. cholerae are still common. Using the Most Probable Number-Polymerase Chain Reac-
tion (MPN-PCR) method, Andrea et al. (2022) found that 3 out of 57 fruits samples (5.3%) and 2 out of 76 vegetables samples
(2.6%) sold in Jakarta were positive for Vibrio cholerae possessing the toxR gene. Twenty-three V. cholerae isolates were recovered
from toxR positive samples and some were antibiotic resistant. As many as 4.35% of the isolates were resistant to gentamicin,
17.39% were streptomycin resistant, 52.17 resistant to trimethoprim, 30.43% to ciprofloxacin, 13.04% to ampicillin (13.04%),
82.61% to nalidixic acid, and 91.30% to polymyxin B. Meanwhile, no isolates exhibited resistance to kanamycin.
Salmonella is a common foodborne pathogen worldwide and is also frequently associated with foods in Indonesia. Salmonellae
were detected in 24.8% of the chicken, beef, fish and vegetables samples tested. Chicken cuts were found to be the most contam-
inated (52.5%), followed by beef (16.7%), fish (10.3%) and vegetables (7.7%). Serotyping of the isolates identified four serotypes:
Salmonella Weltevreden, S. Kentucky, S. Typhimurium and S. Paratyphi C. Most of the isolates (n ¼ 15) exhibited resistance to eryth-
romycin. Only one isolate of S. Kentucky, isolated from chicken cuts, showed intermediate resistance to chloramphenicol. Ten
isolates showed resistance to at least two antibiotics. One strain of S. Weltevreden isolated from beef cuts demonstrated resistance
to four antimicrobial agents (erythromycin, tetracycline, sulfamethoxazole, and streptomycin) (Kusumaningrum et al., 2012). A
recent study by Indrotristanto et al. (2022) recommended that based on the health-risk and economic-risk ranking due to rejection,
Salmonella-shrimp is the top priority on the food-pathogen pair list to be controlled with regard to export of seafoods. For second
and third place were Salmonella-tuna and Listeria monocytogenes-tuna, respectively.
4 Prevalence of Foodborne Diseases in South East Asia

Arisanti et al. (2018) placed Bacillus cereus as the second most common pathogen that causes foodborne outbreaks between 2000
and 2015 as reported by NADFC; however, foods associated with the bacteria has not been fully elucidated. Presence of this path-
ogen in white pepper and chilli, two most commonly spices in Indonesian dishes, has been reported (Nanteza et al., 2022). The
highest presumptive B. cereus level in chili from supermarkets and traditional markets was 8.5  103 and 4.4  103 CFU, respec-
tively. The difference in B. cereus levels between the two market types was not significant. Ten presumptive isolates from chili
and 10 from white pepper were sequenced and 13 were confirmed as B. cereus sensu lato. The sequences were phylogenetically
analyzed and tested for the possession of nheA and ces toxigenic genes. Based on the phylogenetic tree established, 12 of 13 isolates
were identified as B. cereus, sharing >98% similarity with reference strains from GenBank. All 12 isolates (100%) owned the nheA
gene encoding for enterotoxins, but none of them possessed the ces gene encoding for cereulides.
The WHO reported that Campylobacter jejuni was the most frequently isolated foodborne pathogen in SEA region (WHO, 2016).
More recently, a C. jejuni outbreak occurred in Pelabuhan Ratu, West Java causing 137 people to get ill, including 2 deaths (Budiail-
miawan et al., 2022). The outbreak involved mixed meals, including egg and beef rendang, which may have not been cooked appro-
priately and may have experienced cross contamination from washing raw materials with contaminated river water.
Salmonella, E. coli, S. aureus, protozoa and parasites have been isolated from raw vegetables in Jember, East Java. The study re-
ported that 91% of the samples were contaminated with E. coli, 84% contaminated by S. aureus, 79% by V. cholerae, and 36% carry
helminthic larvae while 27% were contaminated with protozoan cysts (Mufida et al., 2022).
It was also reported that in 2018–2019, compliance of the ready-to-eat premises with Ministry of Health hygiene requirements
were 26.4% and 36.7%, respectively. This implies that more than 50% of the ready-to-eat premises did not comply with the require-
ment. The report explains that these foods are predominantly associated with foodborne disease outbreaks in Indonesia. The prob-
able reason is that ready-to-eat foods are often made at household level for personal or public events, such weddings and religious
gatherings (Ministry of Health 2021; unpublished). In 2022 through the month of September, there has been 163 outbreaks
involving 7132 cases with few deaths (CFR 0.1%).

Laos

In Laos, large cholera outbreaks were reported between December 2007–2008 (370 cases including 3 deaths) and 2010 (237 cases
including 4 deaths). The outbreaks were suspected as a results of contaminated drinking water and/or person to person transmis-
sion. In the first outbreak, 17/28 fresh stool were positive for V. cholerae O1 Ogawa strain. Two water sources near the village were
contaminated with the same strain of V. cholerae (Lenglet et al., 2010).
A study to evaluate the level of E. coli contamination in drinking water in association with housing material, toilet availability,
and type of water containers, was conducted in suburban and rural villages in Laos and Thailand in 2011. This study included 121
and 114 households from suburban and rural areas of Laos, as well as 117 and 121 households from suburban and rural Thailand,
respectively. In suburban Laos, housing material, container types and lack of toilets were significantly associated with E. coli contam-
ination of drinking water. Meanwhile in rural Laos, factors affecting the E. coli contamination were rain-fed water, containers with
lids and lack of toilets. E. coli concentrations in drinking water in Laos was higher than those in Thailand, especially in rain-fed water
(mean ¼ 117.7 MPN/100 mL) in suburban Laos and manually collected rainwater in rural Laos (mean ¼ 98.4 MPN/100 mL). The
lowest mean concentration of E. coli was found in the suburban village in Thailand (mean ¼ 3.7 MPN/100 mL). n this study, E. coli
contamination in drinking water was less associated with the socio-demographic characteristics of the respondents (Vannavong
et al., 2018).
The prevalence of Salmonella in foods was reported by Boonmar et al. (2013) who surveyed the presence of the pathogen in 49
meat samples. Among these, 17 beef, 27 pork, 5 buffalo meat samples were obtained from 5 local market in Pakse, Laos. The study
indicated that Salmonella was isolated from 14 (82%) of 17 beef samples, 25 (93%) of 27 pork samples and 4 (80%) of 5 buffalo
meat samples. The 80 Salmonella isolates can be further classified into 11 serovars, i.e., serovars Stanley (n ¼ 15), Anatum (n ¼ 14),
Derby (n ¼ 11), Rissen (n ¼ 9) and Amsterdam (n ¼ 7). Sixty isolates examined were sensitive to ciprofloxacin (100% susceptible),
norfloxacin (100%), cefotaxime (95%), nalidixic acid (90%) and chloramphenicol (88%), but were resistant to streptomycin (67%
resistant), tetracycline (67%) and ampicillin (63%).
Food poisoning after fish consumption, Laos was reported by Luangraj et al. (2022). The outbreak leads to 2 people getting ill
with muscle pain in arms and legs, nausea, vomiting, abdominal cramps, watery diarrhea in one case and fever, myalgia, back pain
which radiated downwards and weakness in both legs in the other. Group B Streptococcus (GBS) ST (sequence type) 283 or Strep-
tococcus agalactiae was suspected to be the causative agent while larb pa nam khong (Mekong fish salad) was the implicated vehicle.
The risk of foodborne infection due to GBS ST283 remains uncertain; however, the pathogen has been reported to cause illness
through tilapia consumption in Singapore and is considered as potential emerging pathogen associated with consumption of
raw freshwater fish in SEA (FAO, 2021).

Malaysia

Most of the foodborne disease reported in Malaysia occurred in school premises. An outbreak in a residential school in Perak State,
Malaysia in April 2016 was reported to involve 111 individuals of students and staff. Sixty-four individuals were defined as cases
 Prevalence of Foodborne Diseases in South East Asia 5

with symptoms such as acute onset of vomiting, diarrhea, and abdominal pain. Clinical laboratory assay of rectal swabs found that
26 out of 29 samples from patients were positive for Salmonella Enteritidis. Roti jala (local bread) was suspected as the vehicle of the
outbreaks since laboratory investigation revealed that the eight food samples tested were positive for Salmonella species, Bacillus
cereus and coagulase positive Staphylococci. Salmonella was concluded as the etiological agent since Salmonella isolated from food
samples and clinical samples showed >99% similarities (Packierisamy et al., 2018).
During the same year, 2589 students were involved in 21 food poisoning outbreaks in all districts of Terengganu, Malaysia
(Abdullah and Ismail, 2021). Students came down with vomiting and diarrhea after consumption of foods from the school canteen.
Foods associated with the outbreaks were poultry (61.9%), rice/grain (14.3%), red meat (9.5%), fish/seafood (9.5%) and eggs
(4.8%). Meanwhile, bacterial pathogens that were epidemiologically linked to the outbreaks include Salmonella spp. (52.4%),
Bacillus cereus (28.6%) and Staphylococcus aureus (19%).
Bacillus cereus and Staphylococcus aureus have also been attributed as the causative agents in an outbreak in a mass gathering in
Petaling district, Selangor, which involved 169 cases aged 7–50 years old. Nasi lemak consisting of rice, sambal (chilli sauce) and
boiled egg was suspected as the vehicle of the outbreak. Five food samples were positive for Bacillus cereus, Staphylococcus aureus
or coliforms, while 10 out of 22 environmental samples were positive for B. cereus and coliform while three of eight hand swabs
from the food handlers were positive for B. cereus and coliform (Rajakrishnan et al., 2022).
Another outbreak reported 33 cases of 188 students eating school canteen meal who met the clinical case definition with symp-
toms such as acute diarrhea, abdominal pain, vomiting, and headache. Consumption of Nasi kuning (yellow rice) increased the risk
to 3,8 times to develop symptoms. Contaminated water used for washing the utensil was thought to be the source (Jeffree and
Mihat, 2016). Bacillus cereus was suspected as the causative agent as it was isolated from a food handler, a hand towel, food prep-
aration areas, serving tables and a water tank.
A survey for the presence of Vibrio parahaemolyticus in 320 seafood samples (banana prawn and red prawn) from local wet market
and supermarket in Malaysia during January-June 2014 has been reported. The results showed that the mean Vibrio count in the
samples ranged from 4.36 log cfu/mL to 6.34 log cfu/mL, Samples from supermarket were less contaminated as compared to
samples from the wet market. Studies using PCR showed that 57.8% (185/320) of the isolates owned the toxR gene suggesting
the ability to produce enterotoxins. The isolation frequency of V. parahaemolyticus in red prawn, i.e. 52% (97/185) was slightly
higher than that in banana prawn at 48% (88/185). It was also found that the isolates were highly susceptible to antibiotics.
They were highly susceptible to imipenem (98%), ampicillin sulbactam (96%), chloramphenicol (95%), trimethoprim-
sulfamethoxazole (93%), gentamicin (85%), levofloxacin (83%), and tetracycline (82%) (Letchumanan et al., 2015).
Food utensils can be the source for contamination. A total of 180 food utensils (60 knives, 60 chopping board, 60 dish plates)
taken from food premises in Kuala Pilah, Malaysia were analyzed for the presence of indicator microorganisms E. coli and coliform
(Saipullizan et al., 2018). The study revealed that 6.7% of knives, 9.7% of chopping board, 3% of dish plates were classified as unac-
ceptable pertaining E. coli contamination. Meanwhile, 66.4% of knives, 73.1% of chopping board, 66.4% of dish plates were also
classified as having unacceptable level of coliforms. The ANOVA revealed that the presence of E. coli and coliforms were significant
across the three types of food utensils [F(2,222) ¼ 21.19, p < 0.05].

Myanmar

In an effort to evaluate personal hygiene program in a hospital, samples of hand swabs and nasal swabs of hospital food handlers in
Mandalay, Myanmar were taken. Of the 111 hand swab samples, 92 showed the presence of S. aureus (42.35%), E. coli (8.11%),
coagulase negative staphylococci (5.41%), and Klebsiella spp. (5.41%). Meanwhile 77 of 111 nasal swab samples revealed the pres-
ence of S. aureus (54.95%), coagulase negative staphylococci (5.41%), and Gram-positive bacilli (5.41%) (Aung, 2020). The result
suggested potential contamination of foods by food handlers.
WHO reported that 50% of fatality due to typhoid fever worldwide occurred in the South East Asia region (WHO, 2016). An
incident of typhoid and paratyphoid (enteric) fevers among adolescents and adults was reported in Yangon, Myanmar. Water
was assumed to be the vehicle due to aging municipal water and sanitation facilities (Oo et al., 2019). Salmonella typhi was isolated
from 33 out of 671 patients from Yangon region while Salmonella paratyphi A was isolated from 9 out of the 671 patients. In Myan-
mar, typhoid fever and paratyphoid fever incidence among adolescents was 360/100,000 persons and 65/100,000 persons, respec-
tively. In addition, typhoid and paratyphoid incidence among adults was 395/100,000 persons and 114/100,000 persons,
respectively.
Large cholera outbreaks consisting of 213 and 250 cases in Yangon Myanmar were reported In 2012 and 2013, respectively. The
detection rates of V. cholerae O1 in stools from patients with severe diarrhea were 23% (49/213 cases) in 2012% and 14% (35/250
cases) in 2013. V cholerae (n ¼ 34) isolated from the outbreaks were found to possess tcpA gene which is a critical colonization factor
in Vibrio (Aung et al., 2015). Another cholera outbreak also occurred in Mandalay in 2015, involving 1617 suspected cholera cases
in which 31 (20.5%) were laboratory-confirmed. All V. cholerae O1 isolated from the outbreak (n ¼ 67) were toxigenic and
belonged to Ogawa serotype, except 1 isolate that was classified as serotype Inaba (Roobthaisong et al., 2017).
Water was the vehicle in acute diarrheal illnesses involving 211 household in a periurban community near Myanmar. Ten of the
211 households (4.74%; CI: 3.0%–9.0%) reported acute diarrhea in children <5 years in the first 2 weeks, 18 households (8.53%;
CI: 5.0%–13.0%) in the second two weeks and 33 households (15.64%; CI: 1.0%–21.0%) cumulatively reported acute diarrhea in
children <5 years within a 1-year period (Myint et al., 2015). The investigation revealed that 94% (105/112) of water samples was
6 Prevalence of Foodborne Diseases in South East Asia

contaminated with thermotolerant coliforms ranging from 2.2 CFU/100 mL to more than 1000 CFU/100 mL. Of the faecal-
coliform-positive water samples, 50% (53/105) was contaminated with E. coli.
Parasites in fresh water fish and Illnesses due to parasites in fish are reported in Myanmar. Chai et al. (2017) reported that fish
from Yangon, Myanmar are commonly infected with various species of the zoonotic trematode (ZT) metacercariae. A study of 264
fish (12 species) collected through December 2013 to June 2015 showed that more than 7 species of ZT metacercariae, i.e., Hap-
lorchis taichui, H. pumilio, H. yokogawai, Centrocestus spp., Stellantchasmus falcatus, Pygidiopsis cambodiensis, and Procerovum sp. were
detected in the samples. Metacercariae of H. taichui were detected in 58 (42.3%) out of 137 fish (5 species), H. pumilio in 96
(49.0%) out of 196 fish (9 species), H. yokogawai in 40 (50.0%) out of 80 fish (5 species), Centrocestus spp. in 91 (50.8%) out
of 179 fish (8 species), S. falcatus and P. cambodiensis were detected in mullets Chelon macrolepis only, while 280 Procerovum sp. meta-
cercariae were found in 6 out of 12 climbing perch, Anabas testudineus. Another parasite found in fish is a nematode Gnathostoma that
causes gnatosthomiasis which is characterized by intermittent subcutaneous migratory swellings due to the helminth larvae. An
outbreak involving 38 cases among Korean emigrants in Myanmar was reported due to freshwater fish consumption that contained
the larvae (Chai et al., 2003). In 2019, 2 cases of ocular gnatosthomiasis were reported. The cases were infected by third stage larvae
of Gnathostoma L3 and Gnathostoma spinige which contaminate uncooked/undercooked freshwater fish dishes (Wai et al., 2020).

Philippines

In the Philippines, a foodborne disease surveillance between 2005 and 2018 reported 209 outbreaks that involved 13,591 cases.
While the causative agents were largely unknown (87.97%), Salmonella spp. (2.46%), Staphylococcal enterotoxin (1.24%), Paralytic
Shelfish Poisoning (PSP) (1.14%), carbamate pesticides (0.96%) and Salmonella Enteritidis (0.82%) were the top 5 causative agents
suspected. The outbreaks mostly occurred in food service eating facilities, such as schools, canteens, restaurants, and hotels (occur-
rence/cases or O/C of 74/4946), followed by household (O/C: 102/4972) and others, such as offices, public gatherings, orphanages,
and jails (O/C: 33/3673). Meanwhile, foods associated with the outbreaks include multiple food dishes (57 occurrences, 27.27%),
meat based dishes (30 occurrences, 14.35%), fish and other seafood dishes (27 occurrences, 12.92%), toxin-containing or inedible
material (22 occurrences, 10.53%), noodles and pasta dishes (21 occurrences, 10.05%), bakery and confectionary (20 occurrences,
9.57%) and rice and root crop (15 occurrences, 7.18%) (Azanza et al., 2019).
Untreated water was the causative agent of a gastroenteritis outbreak after Typhoon Haiyan, in Leyte, Philippines in 2013. Three
out of 11 water samples were positive for Aeromonas hydrophila while Aeromonas hydrophila, Campylobacter jejuni, Campylobacter coli
and Shigella sonnei was isolated from 11 out of 39 rectal swab specimen with a frequency of 4/11, 3/11, 3/11, 1/11, respectively. The
outbreak comprised 105 cases with acute diarrhea (>3 times/24 h), fever, nausea, and vomiting or abdominal pain and 45 were
hospitalized. No fatality was reported in the outbreak (Ventura et al., 2015). Water was also the causative agent in an outbreak
involving 1538 cases with 6 reported deaths in Zamboanga del Sur in 2016. Rotavirus A was isolated from 65 out of 106 cases,
norovirus in 5/106 cases, adenovirus in 1/106 cases while 9/106 cases showed mixed infection. Fifty percent (5/10 samples) of
water was also positive for rotavirus A. Rotavirus genotypes G9P and G3P were identified in both water and human samples (Boni-
facio et al., 2016).
An outbreak in rural village in the Philippines involving 27 suspect cases of Bacillus anthracis was reported in 2017. Although 11
serum specimen and 5 soil samples were negative for B anthracis, the victims showed clinical manifestations similar to B. anthracis
intoxication. The multivariate data analysis suggest that the risk factor was eating uncooked meat of dead buffalo (Adj.OR ¼ 6, 95%
CI:1.7–18.4) (Lonogan et al., 2020).
Vital et al. (2014) studied the microbiological quality of 300 fresh produce samples (bell pepper, cabbage, carrot, lettuce, and
tomato) from 5 open-air markets and 5 supermarkets in the Philippines. The study concluded that 50/300 of the samples (16.7%)
were positive for E. coli, 74/300 were contaminated with Salmonella (24%) and 141 samples recovered somatic phage from produce
wash solutions. The concentration of thermotolerant E. coli was 4.15 log CFU/g, while Salmonella spp. numbers were as high as
2.34 log10 MPN/g. The values of somatic phage in the produce wash are mostly higher than 3.00 log10 PFU/g. The prevalence
of E. coli, Salmonella and somatic phages in the produce samples or produce wash from supermarkets was lower than those from
open-air markets; however, all log values were statistically insignificant between produce samples from open-air and supermarkets
(p  0.05).

Singapore

WHO report in 2016 suggested that the foodborne disease burden in this country has low DALYs, although it was previously re-
ported that there was increase in nontyphoidal salmonellosis from 2001 to 2010 (Kondakcii and Yuk, 2012). Nontyphoid salmo-
nellosis accounted for 56% of foodborne diseases, followed by campylobacteriosis 19%, hepatitis 13%, typhoid fever 10%,
shigellosis 1.2%, cholera 0.5%, and listeriosis 0.4%. Salmonella Enteritidis was the most frequently isolated nontyphoidal Salmonella
(54.3%), followed by S. Stanley (7.7%). S. Weltervreden (7.3%) and S. Typhimurium (3.1%). Nontyphoid salmonellosis was
thought to be increasing between 2006 and 2015 (Zwe and Yuk, 2017). Aik et al. (2020) also reported that 18 months after the
implementation of Food Safety Management System in food service industries, Singapore observed a 78.4% decrease (IRR:
0.216, 95% CI: 0.050–0.940, p ¼ 0.041) in the average level of foodborne outbreaks in food catering service establishments.
 Prevalence of Foodborne Diseases in South East Asia 7

Thailand

A foodborne disease outbreak in a church festival, involving 368 cases with 5% undergoing hospitalization and 50% seeking
medical treatment, was reported between November 28 and December 3, 2020. The suspected etiological agent was Grimontia hol-
lisae and V. parahaemolyticus. Mixed spicy seafood salad had the highest odds ratio and the outbreak was thought to be caused by
undercooked seafood in the salad (Janekrongtham et al., 2021).
Vibrio parahaemolyticus (39.0%) was also found as the most commonly isolated pathogen from rectal swabs of patients in an
outbreak in Kohn Kaen Province of Thailands. The other microorganism isolated were Plesiomonas shigelloides (22.0%),
V. parahaemolyticus and Plesiomonas shigelloides (12.2%) as well as Salmonella spp. (9.8%). Papaya salad is the food with the highest
odds ratio of 2.777 and thus is assumed to be the vehicle. In addition, E. coli, Salmonella enterica, and Staphylococcus were also found
(Nonjui et al., 2020).
Foodborne disease due to norovirus is rarely reported in South East Asia, including Thailand. In 2010, participants in a course
carried out in Thailand experienced foodborne illnesses with an attack ratio of 17%. Samples from four (44%) of the ill persons
were assayed and two (50%) were positive for norovirus. Increased use of norovirus diagnostics and measures to prevent transmis-
sion may have helped identify additional outbreaks and improve control measures to limit the spread of the outbreaks. Investiga-
tion of the outbreak revealed foods with elevated risk ratios include crispy fish maw, dried squid, and cashew salad with a risk ratio
(RR) 5.1% and 95% (CI) 0.7–37; assorted salad bar with dressing with an RR of 3.0; 95% and CI 0.9–11; and seafood kebab with an
RR 5.8 and 95% CI 0.8–43 (McCarthy et al., 2013). Another norovirus outbreak was reported by Phumpholsup et al. (2015) con-
cerning an investigation of a day care center outbreak in 2014 involving eight children and 4 of their household contacts. The inves-
tigation of the 12 cases exhibiting acute gastroenteritis revealed the finding of Norovirus GII.17 in four of seven stool samples.
A survey of foodborne pathogens in 137 retail foods consisting of samples of meat (51), vegetables (38), fish or seafood (37),
and fermented food (11) in seven open markets was carried out in 2011 (Annanchaipattana et al., 2012). The results revealed that
Salmonella spp. was isolated from in 80% meat, 5% vegetable and 9% fermented food samples. Six strains of Cronobacter sakazakii
and two strains of Yersinia enterocolitica were also isolated. The study isolated 7 Listeria spp. from meat and fish or seafood samples.
Approximately 39% of samples were contaminated with Staphylococcus spp. The researcher also found a significantly higher rate of
Bacillus cereus in fermented food (82%) than in meat (2%) and fish or seafood (5%).
As many as 335 samples of Pacific white shrimp (n ¼ 85), oyster (n ¼ 82), Asian seabass (n ¼ 84), and blood cockle (n ¼ 84),
were analyzed for possible contamination of pathogenic bacteria. The results showed that all samples contained fecal coliforms,
85.1% had E. coli; 59% were positive for V. parahaemolyticus, 49% for V. cholerae, 19% for V. alginolyticus, 18% for V. vulnificus,
and 36% were contaminated with Salmonella. Pacific white shrimp (n ¼ 85) has highest concentration of Salmonella Matopeni while
oyster (n ¼ 82) has highest concentration of E. coli (Atwill and Jeamsripong, 2021).
Punsawad et al. (2019) studied the parasites contamination levels in 265 vegetable samples from 3 districts in Thailand and
reported that the overall prevalence of parasitic contamination was 35.1% (93/265). Celery was found to be the most frequently
contaminated sample (63.3%) followed by peppermint (60.0%), gotu kola (57.1%), coriander (44.8%), leek (43.3%), culantro
(36.7%), Chinese cabbage (23.3%), lettuce (20%), and Thai basil (20%), whereas Chinese morning glory (6.7%) was the least
contaminated. Two most predominant parasites in the vegetables were hookworms (16.6%) and Strongyloides stercoralis (10.6%).
The prevalence of intestinal parasite contamination in Mueang district (51.5%) was significantly higher than that in Thasala district
(17.9%) and Sichon district (30.6%) (p < 0.001).
The rate of contamination in cooked pork, chicken meat and cooked aquatic item prepared and sold by small businesses in
Bangkok and Pathum Thani provinces during May 2013 to February 2015 were 13/39 (33%), 18/45 (40%) and 14/57 (25%),
respectively. Meanwhile, the rate of bacterial contamination of collected samples from open-air markets and supermarkets were
26/67 (39%) and 19/68 (27%), respectively. There was no statistically significant difference pertaining to contamination rates
between the two kinds of markets or among the three categories of foods. In each categories of collected food samples, the bacterial
pathogen most commonly found was Staphylococcus aureus (27/135 or 20%) while the least frequently isolated was Salmonella spp.
(4%) (Ananchaipattana et al., 2016).
A survey of a total of 162 samples of food, utensils and food handlers from 4 food service premises in Pakpoon municipality,
Thailand suggested the need for the improvement of food hygienic practices since coliform was found in all samples where coliform
and E. coli counts were >200/hand and >50/hand, respectively (Bumyut et al., 2022).

Vietnam

In 2013 a salmonellosis outbreak linked to bread take-away shop in Ben Tre City, Vietnam was reported. As many as 163 cases met
the case definition which included the following symptoms: fever (100%), diarrhea (100%), abdominal pain (83%), vomiting
(76%), nausea (68%), headache (61%), myalgia (20%), and bloody diarrhea (17%). Stuffed bread made of pork bologna, pork
pate, salted and dried pork, and raw egg mayonnaise was found to contain Salmonella and E. coli. Specimens from 7 out of 16
patients were positive for Salmonella but not for E. coli. Poor hygiene practices at three food preparation sites, presence of insect
and use of kitchenware for both cooked and raw foods as well as absence of health certificates for six workers were thought to
contribute to the contamination of the food (Vo et al., 2014).
8 Prevalence of Foodborne Diseases in South East Asia

Large outbreaks involving S. aureus have been reported more than once between 2018 and 2020. Hung et al. (2020) reported two
large scale outbreaks etiologically linked to S. aureus. The first one reported in 2017 was an outbreak in at wedding involving 152
cases with 109 hospitalizations. Glutinous rice cake was the vehicle linked to the outbreak. An etiological study found two different
S. aureus strains, one carrying sea toxin genes and femA and the other with possession of sec and femA. The second outbreak occurred
in a school was reported in 2018 and resulted in 279 cases including 170 hospitalizations. The food associated with the outbreak
was minced pork while the etiology was linked to S. aureus strains carrying femA and sec genes. No death was reported in the two
outbreaks.
Another large foodborne disease outbreak among primary school children was reported in Vietnam in 2020. Symptoms
including vomiting, abdominal pain, nausea, fever, diarrhea were experienced by 926 schoolchildren in which 352 required hospi-
talization. Coagulase positive-Staphylococcus aureus was confirmed as the causative agent with 20 out of 21 stool samples of children
and 5 out of 6 stool samples of kitchen workers contained coagulase-positive S. aureus while 6 vomit samples also contained
coagulase-positive S. aureus (6.0  101–3.3  103 cfu/mL). The outbreak strain was identified as sequence type 6 (ST6), spa type
t701, was coa-positive, and carried two classical enterotoxin genes, sea and sec. S. aureus was isolated from deep-fried shrimp
(5.0  102 CFU/g) and chicken floss (1.5  103 CFU/g) and 2 samples of frozen chicken used for lunch contained coagulase-
positive S. aureus. S. aureus isolated from chicken floss and frozen chicken was found to produce enterotoxins (Le et al., 2021).
The first botulism outbreak in Southern Vietnam was reported in July-August 2020 involving 6 patients who required intubation
and mechanical ventilation (Ho et al., 2022; Ngan et al., 2020). Food associated with outbreak was canned vegetarian mushroom
pâté produced by small-scale family-run business by handmade methods. C. botulinum was detected in the food samples, however
C. botulinum was not isolated from serum and stool specimens the patients who experienced nausea, vomiting, abdominal pain,
blurred and double vision, dysarthria, dysphagia, ptosis, dyspnea, and limb weakness. Seven additional cases linked to the same
food product were also identified during the above time. In two of seven cases, C. botulinum was detected in both clinical and
food samples. Ten out of 13 patients received the antitoxin after 4 weeks of illness, when three victims had been succesfully weaned
from mechanical ventilation.
Studies in the epidemiology and etiology of diarrheal disease in infants in southern Vietnam reported that 1690 diarrheal
diseases were recorded through clinic-based surveillance. Out of these 1690 cases, 1309 cases had corresponding stool sample
(77%). As many as 748 out of 1309 samples were tested positive for 1 or more pathogen (57%). Rotavirus was the most commonly
detected pathogen (53%) and norovirus was identified in 24% of samples. Using PCR analysis, the presence of Campylobacter,
Salmonella, Shigella and were identified in 20% (n ¼ 152), 18% (n ¼ 135) and 16% (n ¼ 117) of samples, respectively. Of the
Campylobacter infections, C. jejuni was the most often detected causative agent (94%, 143/152), followed by C. coli (6%). Mixed
infections accounted for 26% (192/748) of all positive samples, most of which (68%, 130/192) were a mixed viral/bacterial infec-
tion (Anders et al., 2015).
Iced tea made of unsafe water caused an outbreak with 60 of 71 diarrheal patients with cholera symptoms that occurred May-
August 2010. V. cholerae O1 Ogawa, El Tor biotype was isolated from all cases. Two out of 25 river water samples and one out of 6
wastewater samples were positive for V. cholerae. PCR analysis revealed the presence of V. cholerae O1 Ogawa carrying ctxA in all of
these 3 positive-culture samples. V. cholerae was absent in 2 samples of drinking water, 6 samples of indoor water, and 27 samples of
fresh seafood. Individuals who reported drinking iced tea (adjusted OR (aOR) ¼ 8.40, 95% CI: 1.84–39.25), not always boiling
drinking water (aOR ¼ 2.62, 95% CI: 1.03–6.67), living with people who had acute diarrhea (aOR ¼ 13.72, 95% CI: 2.77–
67.97), having the main household sources of water for use close to a toilet (aOR ¼ 4.36, 95% CI: 1.37–13.88), and having little
or no education (aOR ¼ 4.89, 95% CI: 1.18–20.19) were significantly associated with an elevated risk of cholera (Nguyen et al.,
2017).
Foodborne helminthic parasites remain challenges to human health as well as animal productivity in Vietnam. Consumption of
raw pork has been associated with a trichinosis outbreak involving 24 cases. Trichinella spiralis was detected using ELISA and the
larvae was detected in the muscle (De et al., 2012). A study to determine the seroprevalence and risk factors of trichinosis and cysti-
cercosis pigs and farmer’s perceptions was reported recently (Le et al., 2022). Of 352 pig sera samples, the seroprevalence of trich-
inellosis was 13.6% (95% CI 10.2–17.7) while T. solium cysticercosis was 1.7% (95% CI 0.6–3.7). The seroprevalence of
trichinellosis was significantly higher in female and older pigs. In addition, risk perception and knowledge of interviewed farmers
on both human and swine trichinellosis and cysticercosis was poor. Risky practices include free roaming of pigs and eating under-
cooked or fermented pork. Another commodity frequently linked to helminthic parasites in Vietnam is aqua cultured fish. As many
as 268 helminth species have been reported in 213 fish species, among which are digeneans, monogeneans, cestodes, nematodes
and acanthocephalans. The helminths, which are mostly zoonotic, pose risk in the community due to the habit of eating raw fish
(Nguyen et al., 2020).
Review of foodborne bacterial and parasitic zoonoses in Vietnam was reported by Carrique-Mas and Bryant (2013). The report
suggests non-typhoidal Salmonella (NTS) was mainly caused by Salmonella enterica. Campylobacter jejuni is the dominant species
found in pediatric clinical cases (85%) and in poultry meat (28%–31%). Clinical L. monocytogenes infection was confirmed among
three patients with meningitis in Hanoi in 2008–2009. The pathogen was isolated from unpasteurized soft cheese, processed meat,
and fish product. In Vietnam, important food-pathogen pairs include: undercooked pork blood/intestinedStreptococcus suis, pork-
Leptospira, pork-Toxoplasma, water-Cryptosporidium parvum, water-Giardia lamblia, undercooked beef and pork-Taenia spp., under-
cooked/fermented pork-Taenia spiralis, water, freshwater plant, goatdFasciola hepatica, and undercooked crustaceans- Paragonimus
(Carrique-Mas and Bryant, 2013).
 Prevalence of Foodborne Diseases in South East Asia 9

Conclusions

FBDs are diseases caused by ingestion of food contaminated by biological, chemical and physical hazards. Biological hazards,
including bacteria, viruses and parasites in foods; pose major heath risks in countries of South East Asia. In the South East Asia
region, the types of contaminants in foods is still dominated by bacterial enteric pathogens, protozoa and parasites.
Contamination is generally a result of inadequate control in food production and/or manufacturing which compromises the
safety of foods. While responsibility for food safety primarily rests with the food sector national governments, however, have a crit-
ical role in ensuring food safety, by establishing effective national food control system. FAO/WHO (2003) defined food control as
“a mandatory regulatory activity of enforcement by national or local authorities to provide consumer protection and ensure that all
foods during production, handling, storage, processing, and distribution are safe, wholesome and fit for human consumption;
conform to safety and quality requirements; and are honestly and accurately labeled as prescribed by law”. Food control systems
generally aim to protect public health by reducing the risk of foodborne illness, protect consumers from unsanitary, unwholesome,
mislabeled, or adulterated food; and contribute to economic development by maintaining consumer confidence in the food system
and providing a sound regulatory foundation for domestic and international trade in food (FAO/WHO, 2003).
With various challenges faced in the Southeast Asian region, collaborative efforts of each country with various parties have been
established and various programs have been developed in order to reduce instances of foodborne disease outbreaks. These activities
are aimed to achieve the Sustainable Development Goals (SDGs) related to zero hunger, good health and well-being, poverty elim-
ination, gender equality, water and sanitation, sustainable production and consumption, and climate change. WHO has carried out
a 5-year evaluation (2014–2019) of countries of the Association of South East Asian Countries (ASEAN) regarding their progress on
the development of a national food safety policy and action plan to establish a functional National Codex Committee (NCC) and
national FBD surveillance system, and enact food safety standards and regulations. This resulted in a framework for action on food
safety in the WHO South East Asia Region, to reach the regional food safety goal with five indicators, namely, (1) documented
national food safety policies, (2) established national Codex committees and functional INFOSAN (International Food Safety
Authority Network) emergency contact points and focal points with active participation at regional and global meeting, (3) formu-
lated protocols and mechanisms for investigating outbreaks of FBDs (4) established national surveillance system for FBDs, and (5)
established standards, legislation and monitoring criteria for the entire food supply chain, including street foods (WHO, 2020).

References

Abdullah, N.B.A., Ismail, A.F., 2021. Food poisoning outbreaks among schoolchildren in Terengganu and their associated factors. Sains Malays. 50 (4), 1027–1036.
Agtini, M.D., Soeharno, R., Lesmana, M., Punjabi, N.H., Simanjuntak, C., Wangsaputra, F., Nurdin, D., Pulungsih, S.P., Rofiq, A., Santoso, H., Pujarwoto, H., Sjahrurachman, A.,
Sudarmono, P., von Seidlein, L., Deen, J.L., Ali, M., Lee, H., Kim, D.R., Han, O., Park, J.K., Suwandono, A., Ingerani, Oyofo, B.A., Campbell, J.R., Beecham, H.J., Corwin, A.L.,
Clemens, J.D., 2005. The burden of diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: findings from 24 months surveillance. BMC Infect. Dis. 5, 89. http://www.
biomedcentral.com/1471-2334/5/89.
Aik, J., Turner, R.M., Kirk, M.D., Heywood, A., Newall, A.T., 2020. Evaluating food safety management systems in Singapore: a controlled interrupted time-series analysis of
foodborne disease outbreak reports. Food Control 107324. https://doi.org/10.1016/j.foodcont.2020.107324.
Ananchaipattana, C., Hosotani, Y., Kawasaki, S., Pongsawat, S., Latiful, B.M., Isobe, S., Inatsu, Y., 2012. Prevalence of foodborne pathogens in retailed foods in Thailand.
Foodborne Pathog. Dis. 9 (9), 835–840. https://doi.org/10.1089/fpd.2012.1169. PMID: 22953752.
Ananchaipattana, C., Latiful, B.M., Inatsu, Y., 2016. Bacterial contamination in ready-to-eat foods sold in Middle Thailand. Biocontrol Sci. 21 (4), 225–230. https://doi.org/10.4265/
bio.21.225. PMID: 28003629.
Anders, K.L., Thompson, C.N., Thuy, N.T.V., Nguyet, N.M., Tu, L.T.P., Dung, T.T.N., Phat, V.V., Van, N.T.H., Hieu, N.T., Tham, N.T.H., Ha, P.T.T., Lien, L.B., Chau, N.V.V., Baker, S.,
Simmons, C.P., 2015. The epidemiology and aetiology of diarrhoeal disease in infancy in southern Vietnam: a birth cohort study. Int. J. Infect. Dis. 35 (1), 3–10. https://doi.org/
10.1016/j.ijid.2015.03.013.
Andrea, B., Kurnia, K., Waturangi, D.E., 2022. Prevalence and molecular characterization of Vibrio cholerae from fruits and salad vegetables sold in Jakarta, Indonesia, using most
probable number and PCR. BMC Res. Notes 15, 63.
Arisanti, R.R., Indriani, C., Wilopo, S.A., 2018. Contribution of agent and factors for foodborne disease outbreaks in Indonesia: systematic assessment (in Bahasa Indonesia:
Kontribusi agen dan faktor penyebab kejadian luar biasa keracunan pangan di Indonesia: kajian sistematis). Community Medical News (Berita Kesehatan Masyarakat) 34 (3).
https://doi.org/10.22146/bkm.33852.
Atwill, E.R., Jeamsripong, S., 2021. Bacterial diversity and potential risk factors associated with Salmonella contamination of seafood products sold in retail markets in Bangkok,
Thailand. PeerJ 9, e12694. https://doi.org/10.7717/peerj.12694.
Aung, S.T., 2020. Bacterial assessment and their antibiotic sensitivity patterns of nasal and hand swab specimens from food handlers in hospital compounds in Mandalay, Myanmar:
a cross sectional descriptive or observational study. Res. Sq. 1–14. https://doi.org/10.21203/rs.3.rs-75468/v1.
Aung, W.W., Okada, K., Na-Ubol, M., Natakuathung, W., Aye, M.M., Sandar, T., Oo, N.A.T., Hamada, S., 2015. Cholera in Yangon, Myanmar, 2012–2013. Emerg. Infect. Dis. 21
(3), 543–544. https://doi.org/10.3201/eid2103.141309.
Azanza, M.P.V., Membrebe, B.N.Q., Sanchez, R.G.R., Estilo, E.E.C., Dollete, U.G.M., Feliciano, R.J., Garcia, N.K.A., 2019. Foodborne disease outbreaks in the Philippines (2005–
2018). Philipp. J. Sci. 148 (2), 317–336. ISSN 0031 – 7683.
Bonifacio, J.M., Igoy, M.A., Lupisan, S., Tandoc, A., 2016. Environmental persistence of human rotavirus causing a large outbreak in Western Mindanao, Philippines, 2016. Int. J.
Infect. Dis. 53 (1), 67–68. https://doi.org/10.1016/j.ijid.2016.11.170.
Boonmar, S., Morita, Y., Pulsrikarn, C., Phattharaphron, C., Pornruagwong, S., Chaunchom, S., Sychanh, T., Khounsy, T., Sisavath, D., Yamamoto, S., Sato, H., Ishioka, T.,
Noda, M., Kozawa, K., Kimura, H., 2013. Salmonella prevalence in meat at retail markets in Pase, Champasak Province, Laos, and antimicrobial susceptibility of isolates. J. Glob.
Antimicrob. Resist. 1 (1), 157–161. https://doi.org/10.1016/j.jgar.2013.05.001.
Budiailmiawan, L., Parwati, I., Rita, C., Lokida, D., 2022. Campylobacteriosis in an outbreak of foodborne disease at Bantar Gadung village Palabuhan Ratu. Indonesian J. Clin.
Pathology Med. Laboratory 28 (2), 209–214.
Bumyut, A., Makkaew, P., Yadee, K., Hlamchoo, S., Binyoosoh, I., Precha, N., 2022. Assessment of food safety conditions at food service premises using Thai survey form and field
fecal indicator testing in Pakpoon municipality of Nakhon Si Thammarat, Thailand. Food Sci. Technol. 42. https://doi.org/10.1590/fst.47521.
10 Prevalence of Foodborne Diseases in South East Asia

Carrique-Mas, J.J., Bryant, J.E., 2013. A review of foodborne bacterial and parasitic zoonoses in Vietnam. EcoHealth 10, 465–489. https://doi.org/10.1007/s10393-013-0884-9.
Chai, J.-Y., Sohn, W.M., Na, B.-K., Park, J.-B., Jeoung, H.-G., Hoang, E.-H., Tin, H.H., 2017. Zoonotic trematode metacercariae in fish from Yangon, Myanmar and their adults
recovered from experimental animals. Korean J. Parasitol. Korean Soc. Parasitol. https://doi.org/10.3347/kjp.2017.55.6.631.
Chai, J.Y., Han, E.T., Shin, E.H., Park, J.H., Chu, J.P., Hirota, M., Nakamura-Uchiyama, F., Nawa, Y., 2003. An outbreak of gnathostomiasis among Korean emigrants in Myanmar.
Am. J. Trop. Med. Hyg. 69 (1), 67–73.
Chan, T.K.Y., 2015. Ciguatera fish poisoning in East Asia and Southeast Asia. Mar. Drugs 13 (6), 3466–3478.
De, N.V., Trung, N.V., Ha, N.H., Nga, V.T., Ha, N.M., Thuy, P.T., Duyet, L.V., Chai, J.Y., 2012. An outbreak of trichinosis with molecular identification of Trichinella sp. in Vietnam.
Kor. J. Parasitol. 50 (4), 339–343. https://doi.org/10.3347/kjp.2012.50.4.339.
Dewanti-Hariyadi, R., Gitapratiwi, D., 2014. Prevalence of foodborne diseases in South East and Central Asia. In: Motarjemi, Y. (Ed.), Encyclopedia of Food Safety, vol. 1. Academic
Press, Waltham, MA, pp. 287–294.
FAO [Food Agriculture Organization], 2021. Risk Profile-Group B Streptococcus (GBS)dStreptococcus agalactiae ST283. https://doi.org/10.4060/cb5067en. Bangkok.
FAO/WHO, 2003. Assuring Food Safety and Quality: Guidelines for Strengthening National Food Control Systems. Joint FAO/WHO Publication. Available at. https://www.fao.org/
publications/card/en/c/92f82d38-5557-4ca1-b361-be14cd129db6/. (Accessed 18 July 2022).
Hatta, W., Sudarwanto, M., Sudirman, I., Malaka, R., 2013. Prevalence and sources of contamination of Escherichia coli and Salmonella spp. in cow milk dangke, Indonesian fresh
soft cheese. Glob. Vet. 11 (3), 352–356. ISSN 1992-6197.
Havelaar, A.H., Kirk, M.D., Torgerson, P.R., Gibb, H.J., Hald, T., et al., 2015. World health organization global estimates and regional comparisons of the burden of foodborne
disease in 2100. PLOS Med. https://doi.org/10.1371/journal.pmed.1001923.
Ho, T.H., Nguyen, H.P.A., Le, N.D.T., Hoang, P.H., Ha, N.T., Van Dang, C., 2022. An outbreak of type B botulism in southern Viet Nam, 2020. West. Pac. Surveill. Response J. 13
(1), 1–7.
Hung, L.Q., Nguyen, H.M., Yen, T.T., Hoa, L.V., Ba, T.H., Quyen, P.L., Huong, D.T.T., Trung, N.T., Hao, L.T.H., 2020. Isolation and characterization of Staphylococcus aureus from
two large-scalefood poisoning outbreaks in Vietnam. Health Risk Anal. Epidemiol. 3, 138–146. https://doi.org/10.21668/health.risk/2020.3.17.eng.
Indrotristanto, N., Andarwulan, N., Fardiaz, D., Dewanti-Hariyadi, R., 2022. Prioritization of food-pathogen pairs in export refusals of fishery commodities from Indonesia. J. Food
Control 131. https://doi.org/10.1016/j.foodcont.2021.108476. Online.
Janekrongtham, C., Dejburum, P., Sujinpram, S., Rattanathumsakul, T., Swaddiwudhipong, W., 2021. Outbreak of seafood related food poisoning from undetectable Vibrio
parahaemolyticus-like pathogen, Chiang Mai Province Thailand, December 2020. Trop. Med. Int. Health 27, 92–98.
Jeffree, S.M., Mihat, O., 2016. Waterborne food poisoning outbreak of Bacillus cereus in primary school Sabah East Malaysia. J. Adv. Res. Med. 3 (2&3), 22–29. ISSN:
2349-7181.
Kon, J., 2022. Gastroenteritis cases among children on the rise. Borneo Bulletin. Sept. 14, 2022.
Kondakci, T., Yuk, H.-G., 2012. Overview of Foodborne Outbreak in the Last Decade Singapore: Alarming Increase in Nontyphoidal Salmonellosis. Singapore Institute of Food
Technology. December 2012/2013.
Kusumaningrum, H.D., Suliantari, Dewanti-Hariyadi, R., 2012. Multidrug resistance among different serotypes of Salmonella isolates from fresh products in Indonesia. Int. Food Res.
J. 19 (1), 57–63.
Lawpoolsri, S., Kaewkungwal, J., Khamsiriwatchara, A., Sovann, L., Sreng, B., Phommasack, B., Kitthiphong, V., Lwin Nyein, S., Win Myint, N., Dang Vung, N., Hung, P.,
Smolinski, S., Crawley, M.W., Oo, K.M., 2018. Data quality and timelines of outbreak reporting system among countries in Greater Mekong subregion: challenges for international
data sharing. PLoS Negl. Trop. Dis. 12 (4), e0006425. https://doi.org/10.1371/journal.pntd.0006425.
Le, H.H.T., Dalsgaard, A., Andersen, P.S., Nguyen, H.M., Ta, Y.T., Nguyen, T.T., 2021. Large-scale Staphylococcus aureus foodborne disease poisoning outbreak among primary
school children. Microbiol. Res. 12 (1), 43–52. https://doi.org/10.3390/microbiolres12010005.
Le, T.T.-H., Vu-Thi, N., Dang-Xuan, S., Nguyen-Viet, H., Pham-Duc, P., Nguyen-Thanh, L., Pham-Thi, N., Noh, J., Mayer-Scholl, A., Baumann, M., Meemken, D., Unger, F., 2022.
Seroprevalence and associated risk factors of trichinellosis and T. Solium cysticercosis in Indigenous pigs in Hoa Binh province, Vietnam. Trop. Med. Infect. Dis. 7 (4), 57. https://
doi.org/10.3390/tropicalmed7040057.
Lenglet, A., Khamphaphongpane, B., Thebvongsa, P., Vongprachanh, P., Sithivong, N., Chantavisouk, C., Tsuyuoka, R., 2010. A cholera epidemic in Sekong Province, Lao People’s
Democratic Republic, December 2007-January 2008 May 2010. Jpn. J. Infect. Dis. 63 (3), 204–207. https://doi.org/10.7883/yoken.63.204.
Letchumanan, V., Yin, W.F., Lee, L.H., Chan, K.G., 2015. Prevalence and antimicrobial susceptibility of Vibrio parahaemolyticus isolated from retail shrimps in Malaysia. Front.
Microbiol. 6 (33), 1–12. https://doi.org/10.3389/fmicb.2015.00033.
Lonogan, de Guzman, A., Reyes, V.C.D., Sucaldito, M.N., Avelino, F., 2020. Case-control study of gastro-intestinal outbreak in a rural village, Philippines. Int. J. Infect. Dis. 101 (1),
529–530. https://doi.org/10.1016/j.ijid.2020.09.1371.
Luangraj, M., Hiestand, J., Rasphone, O., Chen, S.L., Davong, V., Barkham, T., Simpson, A.J.H., Dance, D.A.B., Keoluangkhot, V., 2022. Invasive Streptococcus agalactiae ST283
infection after fish consumption in two sisters, Lao DPR. Wellcome Open Res. 7 (148), 1–7. https://doi.org/10.12688/wellcomeopenres.17804.1.
McCarthy, K., Guntapong, R., Thattiyaphong, A., Wangroongsarb, P., Hall, A.J., Olsen, S.J., Holtz, H., 2013. Outbreak of norovirus gastroenteritis infection, Thailand. Southeast
Asian J. Trop. Med. Publ. health 44 (3), 409–416.
Mufida, D.C., Putri, E.R.M., Agustina, D., Suswati, E., Shodikin, M.A., Armiyanti, Y., Hermansyah, B., Utami, W.S., Raharjo, A.M., 2022. Bacterial and parasitic contamination of raw
vegetable in Jember regency, Indonesia: potential risk for food-borne diseases. Int. J. Publ. Health Sci. 4 (11). https://doi.org/10.11591/ijphs.v11i4.21875.
Murang, Z.R., Muharram, S.H., Abiola, O., 2014. Investigating Brunei’s seafood markets for Vibrio parahaemolyticus using Most Probable Number-Polymerase Chain Reaction.
Asian J. Med. Sci. 5 (2), 33–39.
Myint, S.L.T., Myint, T., Aung, W.W., Wai, K.T., 2015. Prevalence of household drinking-water contamination and of acute diarrhoeal illness in a periurban community in Myanmar.
South-East Asia J. Publ. Health 4 (1), 62–68.
NADFC [National Agency for Drug and Food Control], 2019. Annual report. In: Bahasa Indonesia Laporan Tahunan Badan Pengawas Obat Dan Makanan BPOM 2019.
NADFC [National Agency for Drug and Food Control], 2020. Annual report. In: Bahasa Indonesia Laporan Tahunan Badan Pengawas Obat Dan Makanan, BPOM 2020.
Nanteza, H., Dewanti-Hariyadi, R., Nurjanah, S., 2022. Phylogenic identification of toxigenic Bacillus cereus in chilli and white pepper from Bogor area, Indonesia. The Annals of the
University Dunarea de Jos of Galati, Fascicle VI-Food Technology 46 (2). In press.
Ngan, N.T.T., Tho, V.N.A., Khanh, D.T.N., Hien, V.T.T., Day, J.N., Sang, N.N., Tam, H.T., Thanh, H.T.C., Hung, L.Q., 2020. Botulism outbreak after the consumption of vegetarian
pâté in the south of Vietnam. Wellcome Open Res. 5 (257), 1–7. https://doi.org/10.12688/wellcomeopenres.16372.1.
Nguyen, T.V., Pham, Q.D., Do, Q.K., Diep, T.T., Phan, H.C., Ho, T.V., Do, H.T., Phan, L.T., Tran, H.N., 2017. Cholera returns to southern Vietnam in an outbreak associated with
consuming unsafe water through iced tea: a matched case control study. PLoS Negl. Trop. Dis. 11 (4), 1–15. https://doi.org/10.1371/journal.pntd.0005490.
Nguyen, T.H., Dorny, P., Nguyen, T.T.G., Dermaw, V., 2020. Helminth infections in fish in Vietnam: a systematic review. Int. J. Parasitol. 14, 13–32. https://doi.org/10.1016/
j.ijppaw.2020.12.001.
Nonjui, P., Aunruean, W., Bunloet, A., 2020. Prevalence and risk factors associated with bacterial food poisoning in college students at the primary care unit. Indian J. Publ. Health
Res. Dev. 11 (6). https://doi.org/10.37506/ijphrd.v11i6.10009.
Oo, W.T., Myat, T.O., Htike, W.W., Ussher, J.E., Murdoch, D.R., Lwin, K.T., Oo, M.Z., Maze, M.J., Win, H.H., Crump, J.A., 2019. Incidence of typhoid and paratyphoid fevers among
adolescents and adults in Yangon, Myanmar. Clin. Infect. Dis. 68 (2), 124–129. https://doi.org/10.1093/cid/ciy1109.
Packierisamy, P.R., Haron, R.M.A.R., Mustafa, M., Mahir, H.M.A., Ayob, A., Balan, V., 2018. Outbreak caused by food-borne Salmonella enterica serovar Enteriditis in a residential
school in Perak state, Malaysia in April 2016. Int. Food Res. J. 5 (6), 2379–2384.
 Prevalence of Foodborne Diseases in South East Asia 11

Phumpholsup, T., Theamboonlers, A., Wanlapakorn, N., Felber, J.A., Anugulruengkit, S., Puthanakit, T., Chomto, S., Payungporn, S., Poovorawan, Y., 2015. Norovirus outbreak at
a daycare center in Bangkok 2014. Southeast Asian J. Trop. Med. Publ. Health 46 (4), 616–623.
Punsawad, C., Phasuk, N., Thongtup, K., Nagavirochana, S., Viriyavejakul, P., 2019. Prevalence of parasitic contamination of raw vegetables in Nakhon Si Thammarat province,
southern Thailand. BMC Publ. Health 19 (1). https://doi.org/10.1186/s12889-018-6358-9. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6358-9.
(Accessed 7 July 2022).
Rajakrishnan, S., Ismail, M.Z.H., Jamalulail, S.H., Alias, N., Ismail, H., Taib, S.M., Cheng, L.S., Zakiman, Z., Richai, O., Silverdurai, R.R., Yusof, M.P., 2022. Investigation of
foodborne outbreak at a mass gathering in Petaling district, Selangor, Malaysia. Western Pac. Surveill. Response J. 13 (1), 1–5. https://doi.org/10.5365/wpsar.2022.13.1.860.
Roobthaisong, A., Okada, K., Htun, N., Aung, W.W., Wongboot, W., Kamjumphol, W., Han, A.A., Yi, Y., Hamada, S., 2017. Molecular epidemiology of cholera outbreaks during the
rainy season in Mandalay, Myanmar. Am. J. Trop. Med. Hyg. 97 (5), 1323–1328. https://doi.org/10.4269/ajtmh.17-0296.
Rortana, C., Nguyen-Viet, H., Tum, S., Unger, F., Boqvist, S., Dang-Xuan, S., Koam, S., Grace, D., Osbjer, K., Heng, T., Sarim, S., Phirum, O., Sophia, R., Lindahl, J.F., 2021.
Prevalence of Salmonella spp. and Staphylococcus aureus in chicken meat and pork from Cambodian markets. Pathogens 10 (5), 556. https://doi.org/10.3390/
pathogens10050556.
Saipullizan, S.N.A., Mutalib, S.A., Sedek, R., 2018. Escherichia coli and coliforms level of food utensils at food premises in Kuala Pilah, Malaysia. AIP Conf. Proc. 1940 (020105),
1–5. https://doi.org/10.1063/1.5028020.
Syahrul, F., Wahyuni, C.U., Notobroto, H.B., Wasito, E.B., Adi, A.C., Dwirahmadi, F., 2018. Transmission media of foodborne diseases as an index prediction of Diarrheagenic
Escherichia coli: study at elementary school, Surabaya, Indonesia. Int. J. Environ. Res. Publ. Health 17, 8227.
Thompson, L., Vipham, J., Hok, L., Ebner, P., 2021. Towards improving food safety in Cambodia: current status and emerging opportunities. Glob. Food Secur. 31. https://doi.org/
10.1016/j.gfs.2021.100572.
Vannavong, N., Overgaard, H.J., Hareonviriyaphap, T., Dada, N., Rangsin, R., Sibounhom, A., Stenstrom, T.A., Seidu, R., 2018. Assessing factors of Escherichia coli contamination
of household drinking water in suburban and rural Laos and Thailand. Water Sci. Technol. 18 (3), 886–900. https://doi.org/10.2166/ws.2017.133.
Ventura, R.J., Muhi, E., de los Reyes, V.C., Sucaldito, M.N., Tayag, E., 2015. A community-based gastroenteritis outbreak after Typhoon Haiyan, Leyte, Philippines, 2013. West.
Pac. Surveill. Response J. 6 (1), 1–6. https://doi.org/10.5365/wpsar.2014.5.1.010.
Vital, P.G., Dimasuay, K.G.B., Widmer, K.W., Rivera, W.L., 2014. Microbiological quality of fresh produce from open air markets and supermarkets in the Philippines. Sci. World J.
2014 (219534), 1–8. https://doi.org/10.1155/2014/219534.
Vlieghe, E.R., Phe, T., De Smet, B., Veng, H.C., Kham, C., Lim, K., Koole, O., Lynen, L., Peetermans, W.E., Jacobs, J.A., 2013. Bloodstream infection among adults in Phnom Penh,
Cambodia: key pathogens and resistance patterns. PLoS One 8 (3), e59775. https://doi.org/10.1371/journal.pone.0059775. Epub 2013 Mar 29.PMID: 23555777.
Vo, T.H., Le, N.H., Cao, T.T.D., Nuorti, J.P., Minh, N.N.T., 2014. An outbreak of food-borne salmonellosis linked to a bread takeaway in Ben Tre City,Vietnam. Int. J. Infect. Dis. 26
(1), 128–131. https://doi.org/10.1016/j.ijid.2014.05.023.
Wai, A.P., Oo, A., Lwin, M.M., Boonmar, T., Nawa, Y., 2020. Ocular gnathostomiasis in Myanmar: two cases and literature survey. Eye South East Asia 15 (1), 11–16. https://
doi.org/10.36281/2020010103.
WHO [World Health Organisation], 2016. Burden of Foodborne Diseases in the South-East Asia Region, ISBN 978-92-9022-503-4. World Health Organization, Regional Office for
South-East Asia.
WHO [World Health Organization], 2020. Framework for Action on Food Safety in the WHO South-East Asia Region, ISBN 978-92-9022-768-7.
Zwe, Y.H., Yuk, H.-G., 2017. Food quality and safety in Singapore: microbiology aspects. Food Qual. Saf. 1 (2), 101–105. https://doi.org/10.1093/fqsafe/fyx016.