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Vital Surveillances: Characteristics of Settings and Etiologic Agents of Foodborne Disease Outbreaks — China, 2020

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  • Abstract

    Introduction

    Foodborne diseases are a growing public health problem and have caused a large burden of disease in China. This study analyzed epidemiological characteristics of foodborne diseases in China in 2020 to provide a scientific basis for prevention and control measures.

    Methods

    Data were collected from 30 of 31 provincial-level administrative divisions (PLADs) in the mainland of China, excluding Xizang (Tibet) Autonomous Region, via the National Foodborne Disease Outbreaks Surveillance System. The number and proportion of outbreaks, illnesses, hospitalizations, deaths by setting, pathogen-food category pairs and etiology were calculated.

    Results

    In 2020, 7,073 foodborne disease outbreaks were reported, resulting in 37,454 illnesses and 143 deaths. Among the identified pathogens, microbial pathogens were the most common confirmed etiology, accounting for 41.7% of illnesses. Poisonous mushrooms caused the largest proportion of outbreaks (58.0%) and deaths (57.6%). For venues where foodborne disease outbreaks occur, household had the highest number of outbreaks (4,140) and deaths (128), and catering service locations caused the largest proportion of illnesses (59.9%). Outbreaks occurring between June and September accounted for 62.8% of total outbreaks.

    Conclusions

    Foodborne disease outbreaks mainly occurred in households. Microbial pathogens remained the top cause of outbreak-associated illnesses. Poisonous mushrooms were ranked the top cause of deaths in private homes in China. The supervision and management of food safety and health education should be strengthened to reduce the burden of foodborne diseases. Publicity should be increased to reduce the incidence of mushroom poisonings in families, and supervision and management of food should be strengthened to reduce microbial contamination.

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  • Funding: Supported by The National Key Research and Development Program of China (Grant number 2017YFC1601502)
  • [1] Gould LH, Walsh KA, Vieira AR, Herman K, Williams IT, Hall AJ, et al. Surveillance for foodborne disease outbreaks-United States, 1998−2008. MMWR Surveill Summ 2013;62(2):1−34. https://pubmed.ncbi.nlm.nih.gov/23804024/.https://pubmed.ncbi.nlm.nih.gov/23804024/
    [2] World Health Organization. WHO estimates of the global burden of foodborne diseases. 2015. https://www.who.int/activities/estimating-the-burden-of-foodborne-diseases. [2020-3-13].
    [3] Havelaar AH, Kirk MD, Torgerson PR, Gibb HJ, Hald T, Lake RJ, et al. World Health Organization global estimates and regional comparisons of the burden of foodborne disease in 2010. PLoS Med 2015;12(12):e1001923. http://dx.doi.org/10.1371/journal.pmed.1001923CrossRef
    [4] Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM. Foodborne illness acquired in the United States—unspecified agents. Emerg Infect Dis 2011;17(1):16 − 22. http://dx.doi.org/10.3201/eid1701.091101p2CrossRef
    [5] Fu P, Wang LS, Chen J, Bai GD, Xu LZ, Wang S, et al. Analysis of foodborne disease outbreaks in China mainland in 2015. Chin J Food Hygiene 2019;31(1):64 − 70. http://dx.doi.org/10.13590/j.cjfh.2019.01.014 (In Chinese). CrossRef
    [6] Ren JH, Wang XY, Wu XM, Wang R. Epidemiological characteristics of food poisoning in China, July-September, 2018. Dis Surveill 2019;34(8):741 − 5. http://dx.doi.org/10.3784/j.issn.1003-9961.2019.08.014 (In Chinese). CrossRef
    [7] European Food Safety Authority and European Centre for Disease Prevention and Control (EFSA and ECDC). The European Union summary report on trends and sources of zoonoses, zoonotic agents and food-borne outbreaks in 2017. EFSA J 2018;16(12):e05500. http://dx.doi.org/10.2903/j.efsa.2018.5500CrossRef
    [8] Li WW, Pires SM, Liu ZT, Ma XC, Liang JJ, Jiang YY, et al. Surveillance of foodborne disease outbreaks in China, 2003-2017. Food Control 2020;118:107359. http://dx.doi.org/10.1016/j.foodcont.2020.107359CrossRef
    [9] Centers for Disease Control and Prevention (CDC). Surveillance for foodborne disease outbreaks-United States, 2009–2010. MMWR Morb Mortal Wkly Rep 2013;62(3):41–7. https://pubmed.ncbi.nlm.nih.gov/23344696/.https://pubmed.ncbi.nlm.nih.gov/23344696/
  • TABLE 1.  Number and proportion of foodborne disease outbreaks, illnesses, and deaths by setting in China, 2020.

    SettingOutbreaksIllnessesDeathsFatality rate*
    (%)
    NumberProportion
    (%)
    NumberProportion
    (%)
    NumberProportion
    (%)
    Household4,14058.514,06637.612889.50.9
    Catering Service Places2,71938.422,43259.91510.50.1
    Street stall71210.12,6597.132.10.1
    Hotel restaurant5087.24,18411.253.50.1
    Staff canteen3715.33,6079.610.70.0
    School canteen3104.45,08113.600.00.0
    Bistro2914.11,4733.932.10.2
    Fast food restaurant2403.41,1713.100.00.0
    Rural banquet1301.82,1655.832.10.1
    Home delivery of meal1101.61,8074.800.00.0
    Other470.72850.800.00.0
    Campus270.41960.500.00.0
    Other location1872.67602.000.00.0
    Total7,073100.037,454100.0143100.00.4
    * Fatality rate=number of deaths / number of illnesses.
    Download: CSV

    TABLE 2.  Number and proportion of foodborne disease outbreaks, illnesses, and deaths by etiology in China, 2020.

    EtiologyOutbreaksIllnessesDeathsFatality
    rate* (%)
    NumberProportion (%)NumberProportion(%)NumberProportion(%)
    Poisonous mushrooms2,70538.29,11124.38055.90.9
    Plant and animal toxicants1,02014.44,58412.22114.70.5
    Undercooked Phaseolus*3184.51,5264.100.00.0
    Coriaria sinica1111.63541.000.00.0
    Potherb931.33551.010.70.3
    Aconite841.23371.0128.43.6
    Bitter bottle gourd480.73811.000.00.0
    Tungoil or seed460.72380.600.00.0
    Hyoscyamine330.51830.510.70.6
    Herb-medicine270.41100.300.00.0
    Elephant’s-ear240.3860.200.00.0
    Sproutedpotato/solanine170.2970.321.42.1
    Colchicin120.2780.200.00.0
    Gelsemine110.2640.232.14.7
    Castor bean100.1580.200.00.0
    Pokeberry root100.1420.110.72.4
    Sago seed100.1360.100.00.0
    Barbados nut90.1410.100.00.0
    Undercooked soymilk/Trypsin inhibitor30.0180.100.00.0
    Other plants toxicants§831.22850.800.00.0
    Fish roe190.3510.100.00.0
    Tetrodotoxin150.2530.110.71.9
    Pupae130.2600.200.00.0
    langoustine100.1250.100.00.0
    Other animal toxicants**140.21060.300.00.0
    Bacterial76610.810,48328.01611.20.2
    Salmonella2864.03,4469.242.80.1
    Vibrio parahaemolyticus1281.81,8484.900.00.0
    Staphylococcus aureus751.19542.600.00.0
    Escherichia coli540.81,5204.100.00.0
    Bacillus cereus500.76201.700.00.0
    Bacillus proteus100.11490.400.00.0
    Clostridium perfringens50.12870.800.00.0
    Bongkrek acid††50.1230.1128.452.2
    Campylobacter jejuni30.01330.400.00.0
    Clostridium botulinum30.0100.000.00.0
    Listeria monocytogenes10.0280.100.00.0
    Others1081.58072.200.00.0
    2 or more pathogens120.22240.600.00.0
    Norovirus260.44341.200.00.0
    Chemical agents1632.39222.52215.42.4
    Nitrite801.14571.253.51.1
    Pesticide§§530.82550.721.40.8
    Prohibited drugs100.11150.310.70.9
    Methanol90.1560.2149.825.0
    Other chemical pollutants***110.2390.100.00.0
    Fungi70.1270.100.00.0
    Parasitic10.040.000.00.0
    Unknown etiology2,41134.112,32332.942.80.0
    Total7,073100.037,454100.0143100.00.4
    * Refers to uncooked Phaseolus beans.
    Contained in uncooked soy milk.
    § Including wild flowers, hellebore, wild ginseng, pollen, daffodils, and wild fruits, etc. Including bee pupae and silkworm pupae.
    ** Including dog liver, insects, fish gall, toads and ants, etc.
    †† Including Shigella, Aeromonas, Enterobacter cloacae, Citrobacter flaudus, Schneider, and Enterococcus, etc.
    §§ Including Carbamates, organophosphates, pyrethroids, paraquat, bromfamethamine and bromadiolone, etc. Including clenbuterol hydrochloride, xylazine, and tetramine.
    *** Including lead, engine oil, desiccant, chlorine dioxide, and detergent, etc.
    Download: CSV

    TABLE 3.  Top 10 number and proportion of most common confirmed pathogen-food category pairs resulting in outbreak in China, 2020.

    EtiologyFood categoryNo. outbreaksProportion (%)
    SalmonellaEgg7532.8
    SalmonellaSauce-marinated meat44
    19.2
    SalmonellaPastry2812.2
    Bacillus cereusRice flour229.6
    Vibrio prahaemolyticusSauce-marinated meat177.4
    SalmonellaLivestock meat135.7
    Vibrio parahaemolyticusCrustaceans114.8
    Escherichia coliSauce-marinated meat10
    4.4
    Staphylococcalaureus enterotoxins
    Pastry

    9

    3.9
    SalmonellaPoultry6100.0
    Total22932.8
    Download: CSV

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Characteristics of Settings and Etiologic Agents of Foodborne Disease Outbreaks — China, 2020

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Abstract

Introduction

Foodborne diseases are a growing public health problem and have caused a large burden of disease in China. This study analyzed epidemiological characteristics of foodborne diseases in China in 2020 to provide a scientific basis for prevention and control measures.

Methods

Data were collected from 30 of 31 provincial-level administrative divisions (PLADs) in the mainland of China, excluding Xizang (Tibet) Autonomous Region, via the National Foodborne Disease Outbreaks Surveillance System. The number and proportion of outbreaks, illnesses, hospitalizations, deaths by setting, pathogen-food category pairs and etiology were calculated.

Results

In 2020, 7,073 foodborne disease outbreaks were reported, resulting in 37,454 illnesses and 143 deaths. Among the identified pathogens, microbial pathogens were the most common confirmed etiology, accounting for 41.7% of illnesses. Poisonous mushrooms caused the largest proportion of outbreaks (58.0%) and deaths (57.6%). For venues where foodborne disease outbreaks occur, household had the highest number of outbreaks (4,140) and deaths (128), and catering service locations caused the largest proportion of illnesses (59.9%). Outbreaks occurring between June and September accounted for 62.8% of total outbreaks.

Conclusions

Foodborne disease outbreaks mainly occurred in households. Microbial pathogens remained the top cause of outbreak-associated illnesses. Poisonous mushrooms were ranked the top cause of deaths in private homes in China. The supervision and management of food safety and health education should be strengthened to reduce the burden of foodborne diseases. Publicity should be increased to reduce the incidence of mushroom poisonings in families, and supervision and management of food should be strengthened to reduce microbial contamination.

  • 1. National Health Commission Key Laboratory of Food Safety Risk Assessment, China National Center for Food Safety Risk Assessment, Beijing, China
  • 2. Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, China
  • 3. Guangxi Center for Disease Prevention and Control, Nanning, Guangxi Zhuang Autonomous Region, China
  • 4. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, Guangdong, China
  • 5. Shanxi Provincial Center for Disease Control and Prevention, Taiyuan, Shanxi, China
  • 6. Shandong Center for Disease Control and Prevention, Jinan, Shandong, China
  • 7. Fujian Provincial Center for Disease Control and Prevention, Fuzhou, Fujian, China
  • 8. Anhui Provincial Center for Disease Control and Prevention, Hefei, Anhui, China
  • 9. Shaanxi Provincial Centre for Disease Control and Prevention, Xi’an, Shaanxi, China
  • 10. National Food Institute, Technical University of Denmark, Lyngby, Denmark
  • Corresponding author:

    Ping Fu, fuping@cfsa.net.cn

  • Funding: Supported by The National Key Research and Development Program of China (Grant number 2017YFC1601502)
  • Online Date: October 15 2021
    doi: 10.46234/ccdcw2021.219
    • An outbreak of foodborne disease is defined as the occurrence of two or more cases of a similar illness resulting from ingestion of a common food (1). It is a global health problem that is harmful to humans. Foodborne diseases encompass a wide spectrum of illnesses, including infectious diseases caused by microorganisms and toxic diseases mainly caused by chemical and toxic agents. The World Health Organization estimated that 600 million foodborne diseases occurred globally in 2010, causing 420,000 deaths (2). The US CDC estimated that 48 million foodborne diseases (1 in 6 Americans) occur each year in the USA, resulting in 12,800 hospitalizations and 3,000 deaths (3). In the Western Pacific Region, including China, 125 million people get sick and more than 50,000 die every year due to foodborne diseases (4). Foodborne diseases bring huge economic burdens to human beings. According to the requirements of Food Safety Law of the People’s Republic of China, the National Foodborne Disease Outbreaks Surveillance System was established to continuously and systematically collect data on foodborne disease outbreaks in 2010.

      Therefore, the objectives of this study were to characterize the epidemiological status of foodborne diseases in China and to analyze the distribution of high-risk foods and pathogenic factors to provide technical support for food safety risk assessment, formulation and revision of standards, and risk management.

    • The study obtained data on foodborne disease cases reported through the National Foodborne Disease Outbreaks Surveillance System from January 1, 2020 to December 31, 2020. Data were collected from 30 of 31provincial-level administrative divisions (PLADs) in the mainland of China, excluding Xizang (Tibet) Autonomous Region. Data requested for each outbreak report included the individual CDC reporting the outbreak, date of occurrence, number of illnesses, hospitalizations, and deaths, etiology, implicated food(s) and setting. All variable values were reported as counts or proportions (%). The number and proportion of outbreaks, illnesses, and deaths by etiology, setting, and food categories were calculated. The statistical analysis was performed using SPSS (version 21.0, IBM Corp, Chicago, USA).

    • Most outbreaks (97.5%), illnesses (98.0%), and deaths (99.1%) were linked to households and catering service locations. Households and catering service locations were the most common settings of reported outbreaks. In 2020, the highest number of outbreaks occurred in households (4,140), followed by catering service locations (2,719), and school campuses (27). Most illnesses (59.9%) were reported in catering service locations, followed by households (37.6%), and 0.5% in campuses. Within catering service locations, street stalls accounted for the largest proportion (26.2%) of outbreaks, and school canteens accounted for the largest proportion (13.6%) of illnesses. However, households had the most deaths, accounting for 89.5% of all deaths (Table 1); poisonous mushrooms (79 deaths), aconite (10 deaths), bongkrek acid (11 deaths), and methanol (8 deaths) were the most common causes of deaths, accounting for 84.4% of total deaths in private home settings.

      SettingOutbreaksIllnessesDeathsFatality rate*
      (%)
      NumberProportion
      (%)
      NumberProportion
      (%)
      NumberProportion
      (%)
      Household4,14058.514,06637.612889.50.9
      Catering Service Places2,71938.422,43259.91510.50.1
      Street stall71210.12,6597.132.10.1
      Hotel restaurant5087.24,18411.253.50.1
      Staff canteen3715.33,6079.610.70.0
      School canteen3104.45,08113.600.00.0
      Bistro2914.11,4733.932.10.2
      Fast food restaurant2403.41,1713.100.00.0
      Rural banquet1301.82,1655.832.10.1
      Home delivery of meal1101.61,8074.800.00.0
      Other470.72850.800.00.0
      Campus270.41960.500.00.0
      Other location1872.67602.000.00.0
      Total7,073100.037,454100.0143100.00.4
      * Fatality rate=number of deaths / number of illnesses.

      Table 1.  Number and proportion of foodborne disease outbreaks, illnesses, and deaths by setting in China, 2020.

      In 2020, there were 4,662 outbreaks with confirmed etiology. Poisonous mushrooms were the most common cause of outbreaks and deaths, accounting for 58.0% of outbreaks and 57.6% of deaths; bacterial pathogens were the most common cause of illnesses (41.7%); in poisonous animals and plants and their toxins, undercooked Phaseolus was the most common cause leading to the largest proportion of outbreaks (31.2%) and illnesses (33.3%); aconite had the most deaths, accounting for 57.1%. Within microbial pathogens, Salmonella (286 outbreaks and 3,446 illnesses) was the most common bacterial pathogen associated with outbreaks and illnesses, followed by Vibrio parahaemolyticus (128 outbreaks and 1,848 illnesses), and Staphylococcus aureus (75 outbreaks and 954 illnesses). Bongkrek acid accounted for the largest proportions (75.0%) of deaths and the largest fatality rate (52.2%). Among the chemical agents, nitrite was the most common pathogenic factor associated with outbreaks (49.1%) and illnesses (49.6%), followed by pesticide (32.5% outbreaks and 27.7% illnesses); methanol had the highest death and fatality rates at 63.6% and 25.0%, respectively, followed by nitrite at 22.7% and 1.1%, respectively (Table 2).

      EtiologyOutbreaksIllnessesDeathsFatality
      rate* (%)
      NumberProportion (%)NumberProportion(%)NumberProportion(%)
      Poisonous mushrooms2,70538.29,11124.38055.90.9
      Plant and animal toxicants1,02014.44,58412.22114.70.5
      Undercooked Phaseolus*3184.51,5264.100.00.0
      Coriaria sinica1111.63541.000.00.0
      Potherb931.33551.010.70.3
      Aconite841.23371.0128.43.6
      Bitter bottle gourd480.73811.000.00.0
      Tungoil or seed460.72380.600.00.0
      Hyoscyamine330.51830.510.70.6
      Herb-medicine270.41100.300.00.0
      Elephant’s-ear240.3860.200.00.0
      Sproutedpotato/solanine170.2970.321.42.1
      Colchicin120.2780.200.00.0
      Gelsemine110.2640.232.14.7
      Castor bean100.1580.200.00.0
      Pokeberry root100.1420.110.72.4
      Sago seed100.1360.100.00.0
      Barbados nut90.1410.100.00.0
      Undercooked soymilk/Trypsin inhibitor30.0180.100.00.0
      Other plants toxicants§831.22850.800.00.0
      Fish roe190.3510.100.00.0
      Tetrodotoxin150.2530.110.71.9
      Pupae130.2600.200.00.0
      langoustine100.1250.100.00.0
      Other animal toxicants**140.21060.300.00.0
      Bacterial76610.810,48328.01611.20.2
      Salmonella2864.03,4469.242.80.1
      Vibrio parahaemolyticus1281.81,8484.900.00.0
      Staphylococcus aureus751.19542.600.00.0
      Escherichia coli540.81,5204.100.00.0
      Bacillus cereus500.76201.700.00.0
      Bacillus proteus100.11490.400.00.0
      Clostridium perfringens50.12870.800.00.0
      Bongkrek acid††50.1230.1128.452.2
      Campylobacter jejuni30.01330.400.00.0
      Clostridium botulinum30.0100.000.00.0
      Listeria monocytogenes10.0280.100.00.0
      Others1081.58072.200.00.0
      2 or more pathogens120.22240.600.00.0
      Norovirus260.44341.200.00.0
      Chemical agents1632.39222.52215.42.4
      Nitrite801.14571.253.51.1
      Pesticide§§530.82550.721.40.8
      Prohibited drugs100.11150.310.70.9
      Methanol90.1560.2149.825.0
      Other chemical pollutants***110.2390.100.00.0
      Fungi70.1270.100.00.0
      Parasitic10.040.000.00.0
      Unknown etiology2,41134.112,32332.942.80.0
      Total7,073100.037,454100.0143100.00.4
      * Refers to uncooked Phaseolus beans.
      Contained in uncooked soy milk.
      § Including wild flowers, hellebore, wild ginseng, pollen, daffodils, and wild fruits, etc. Including bee pupae and silkworm pupae.
      ** Including dog liver, insects, fish gall, toads and ants, etc.
      †† Including Shigella, Aeromonas, Enterobacter cloacae, Citrobacter flaudus, Schneider, and Enterococcus, etc.
      §§ Including Carbamates, organophosphates, pyrethroids, paraquat, bromfamethamine and bromadiolone, etc. Including clenbuterol hydrochloride, xylazine, and tetramine.
      *** Including lead, engine oil, desiccant, chlorine dioxide, and detergent, etc.

      Table 2.  Number and proportion of foodborne disease outbreaks, illnesses, and deaths by etiology in China, 2020.

      In 2020, outbreaks that occurred at households (7,073) had surpassed those of catering service units (5,652), and outbreaks (485) and outbreak-associated illnesses (6,661) caused by Salmonella surpassed those of Vibrio parahaemolyticus. Foodborne disease illnesses occurred in school canteens (5,081).

      The top 10 pathogen-food category pairs resulting in outbreaks, outbreak-associated illnesses, and deaths were analyzed. Salmonella in eggs had the highest occurrence, accounting for 32.8% (75/229) of outbreaks, followed by Salmonella in sauce-marinated meat (Table 3). Salmonella in sauce-marinated meat had the highest proportion (21.7%) of illnesses and 23.2% of hospitalizations, followed by Salmonella in eggs.

      EtiologyFood categoryNo. outbreaksProportion (%)
      SalmonellaEgg7532.8
      SalmonellaSauce-marinated meat44
      19.2
      SalmonellaPastry2812.2
      Bacillus cereusRice flour229.6
      Vibrio prahaemolyticusSauce-marinated meat177.4
      SalmonellaLivestock meat135.7
      Vibrio parahaemolyticusCrustaceans114.8
      Escherichia coliSauce-marinated meat10
      4.4
      Staphylococcalaureus enterotoxins
      Pastry

      9

      3.9
      SalmonellaPoultry6100.0
      Total22932.8

      Table 3.  Top 10 number and proportion of most common confirmed pathogen-food category pairs resulting in outbreak in China, 2020.

    • Influenced by the coronavirus disease 2019 (COVID-19) pandemic, epidemiological characteristics of foodborne diseases in China had changed greatly in 2020.

      For the first time in the past 5 years, outbreaks that occurred in private homes had surpassed that of catering service units in 2020 (5). The local residents in mountainous areas of southwest and central China tended to pick mushrooms and poisonous plants frequently in the wild (6). Continued and targeted health education programs should caution against picking wild mushrooms and toxic wild fruits. Eating habits with regional characteristics should be further emphasized and intervention measures should be taken to reduce the occurrence of poisonings.

      The study showed that poisonous mushrooms caused the most deaths, the same as previous studies (5). They were mainly caused by wild mushrooms collected by households (97.5%). This was consistent with the research results of Ren et al. (6). Residents picking and eating mushrooms could not distinguish between poisonous mushrooms from non-toxic mushrooms, and the rate of timely treatment after poisoning was low and increased the risk of death. Health education targeted for specific groups in rural areas is also essential to reduce mushroom poisonings.

      Outbreaks and illnesses caused by Salmonella surpassed that of Vibrio parahaemolyticus, becoming the first pathogenic bacteria of bacterial foodborne diseases. This analysis on pathogen and food pairs in China showed that Salmonella outbreaks were most often linked to eggs, sauce-marinated meat products. Data showed that Salmonella was responsible for the largest number of outbreaks, hospitalizations, and deaths among meats and eggs; this was consistent with the result from the EU: Salmonella accounted for 36.8% of deaths in “eggs and egg products” (7). For Salmonella outbreaks, most outbreak-associated cases in the US were associated with seeded vegetables, eggs, poultry, beef, and pork, which differed from China (8). Pathogenic microbial contamination was still the main pathogenic factor of foodborne diseases in China and an important food safety issue that should not be ignored. Hygiene guidance and education should be done to reduce the burden of foodborne diseases caused by microbial factors.

      Therefore, continued surveillance for foodborne disease outbreaks is important to understand changes in the foods, settings, and pathogens associated with illness (9). In order to reduce public health risks, more measures were adopted to enhance awareness of reporting, improve trace-back technology to achieve early detection, early warning, and early control of food safety risks.

      This study was subject to at least two limitations. First of all, for many reported outbreaks, information on certain aspects of the outbreaks was missing or incomplete, so the conclusions might not be representative of unknown aetiologies or food categories. Second, reported foodborne disease outbreaks can’t represent all actual occurred outbreaks, since underreporting existed for various reasons, such as administrative intervention, insufficient ability of outbreak investigation, etc.

      Not all the National Foodborne Disease Outbreaks Surveillance System recorded with the epidemiological information in 2020. Like most countries, there are also cases of under-report, and incomplete information.

    • Members in all participating CDCs.

    • No reported conflicts.

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