Foodborne and waterborne diseases and outbreaks are a neglected public health issue worldwide. In developing countries, diarrheal disease caused by foodborne and waterborne infections is a major cause of ill health. There is a lack of information on foodborne pathogens, their transmission routes, outbreaks, and related mortalities, due to the absence of a robust disease surveillance system and adequately equipped laboratories. Although hygiene practices are much better in Western countries, the widespread use of preserved and raw food items is a cause of concern. Consequently, the occurrence of foodborne diseases is not rare in these countries either. WHO has recently released the 'Global Strategy for Food Safety 2022-2030', addressing the emerging challenges, new technologies, and innovative approaches to strengthen food safety systems and enhance laboratory capacity for foodborne disease surveillance. Foodborne outbreaks are a huge challenge in India. Malnutrition, anemia, hookworm and enteric infections, are the predominant cryptic health conditions among children in rural and tribal areas, leading to severe consequences, including death, and posing a substantial threat to public health. Combating such events with adequate food safety and hygiene practices is achievable. Systematic collection of data can help to develop food safety policies that could reduce the burden of foodborne diseases. This review aims to examine the current situation of foodborne and waterborne diseases, identification of the factors contributing to their occurrence and outbreaks, and defining the gaps in control measures, challenges, and potential solutions in improving the public health system. Strengths, weaknesses, opportunities, and threats (SWOT) analysis was made based on the literature review of foodborne and waterborne infections to assess the current situation and to identify knowledge gaps. SWOT analysis showed the strength and gaps in the different national initiatives analogous to the global programs. Though, Integrated Disease Surveillance Programme (IDSP), Food Safety and Standards Authority of India (FSSAI), the core Government missions, independently generate substantial information, sporadic and outbreak cases of diarrhea still prevail in the country due to the absence of a systematic national surveillance system. Recently, many government initiatives have been made through Sustainable Development Goals (SDGs), G20 goals, etc. However, potential threats such as risk of zoonotic disease transmission to humans, emerging infections and antimicrobial resistance (AMR), and unauthorized activities in the food sector pose a big challenge in safeguarding the public health. Maintenance of global food safety requires a systematic analysis of present situations, identification of existing shortcomings, and targeted efforts toward prevention of infections. The ongoing G20 mission and the SDGs for 2030 represent significant strides in this direction. To have pathogen-free animals and supply of contamination-free raw foods is impractical, but, mitigating the prevalence of zoonotic diseases can be accomplished by rigorously enforcing hygiene standards throughout the food production chain. A crucial requirement at present is the implementation of integrated laboratory surveillance for foodborne and waterborne infections, as this will provide policymakers and stakeholders all the evidence based scientific information. This system will facilitate efforts in minimizing the risks associated with foodborne and waterborne infections.

Background: Food safety is a critical factor in promoting public health and nutrition, especially in developing countries like India, which experience several foodborne disease outbreaks, often with multidrug-resistant pathogens. Therefore, implementing regular surveillance of enteric pathogens in the human-animal-environment interface is necessary to reduce the disease burden in the country. Objective: To establish a network of laboratories for the identification of major food and waterborne pathogens prevailing in the northeast region of India through integrated surveillance of animal, food, human, and environment and investigate the antimicrobial susceptibility pattern of the pathogens of public health significance. Methods: The Indian Council of Medical Research (ICMR) has identified FoodNet laboratories; based on their geographical location, inclination to undertake the study, preparedness, proficiency, and adherence to quality assurance procedures, through an 8-step process to systematically expand to cover the Northeastern Region (NER) with comprehensive diagnostic capacities for foodborne pathogens and diarrhea outbreak investigations. Network initiated in the NER given the unique food habits of the ethnic population. Findings: This surveillance network for foodborne enteric pathogens was established in Assam, Arunachal Pradesh, Tripura, and Sikkim, and expanded to other four states, i.e., Manipur, Mizoram, Meghalaya, and Nagaland, thereby covering the entire NER by including nine medical and three veterinary centers. All these centers are strengthened with periodic training, technical support, funding, capacity building, quality assurance, monitoring, centralized digital data management, and website development. Results: The ICMR-FoodNet will generate NER-specific data with close to real-time reporting of foodborne disease and outbreaks, and facilitate the updating of food safety management protocols, policy reforms, and public health outbreak response. During 2020-2023, 13,981 food samples were tested and the detection of enteric pathogens ranged from 3 to 4%. In clinical samples, the detection rate of the pathogens was high in the diarrheal stools (8.9%) when 3,107 samples were tested. Thirteen outbreaks were investigated during the study period. Conclusion: Foodborne diseases and outbreaks are a neglected subject. Given the frequent outbreaks leading to the deaths of children, it is crucial to generate robust data through well-established surveillance networks so that a strong food safety policy can be developed for better public health.

Circulation of antimicrobial resistant (AMR) bacteria in the environment, animals, and humans is a major concern. Food chain is an important link to spread AMR across the biosphere. Global warming, preserved and fast foods availability, random use of un-prescribed antimicrobials, unplanned bio-waste management, and using high doses of antibiotics and bio-fertilizers to agricultural fields and animal farms, increase the threat of spreading AMR bacteria. Current study reports prevalence of AMR in enteric pathogens isolated from food, food handlers, environment, and diarrheal patients. The incidence data on AMR pathogens were collected from Assam, Sikkim, Tripura, and Arunachal Pradesh, India, through a well-structured market and hospital surveillance. There were 428 (3.0%) enteric pathogens detected in food and 184 (5.3%) in clinical samples. Most of the pathogens were resistant (70–100%) to commonly used antimicrobials in treatment of diarrheal infection. Result showed a spread of AMR across food chain, underscoring need for swift preventive intervention.

Traditional and fermented foods are widely consumed by the ethnic population of Northeast India. These foods are not only very nutritious, easily available, and reasonably priced, but also boost immunity and protect from various seasonal infections and have been reported through several investigations. However, pathogens transmitted by these foods have never been reported. The process of preparation and preservation of fermented traditional foods involves various steps that can prompt contamination risks. Using the Indian Council of Medical Research (ICMR)-FoodNet surveillance data, we report the profile of enteric bacteria and mycotoxin-producing fungal pathogens identified in traditional and fermented food items and their importance in public health. Food samples were collected from rural areas of Assam, Arunachal Pradesh, Tripura, and Sikkim. Bacterial and fungal pathogens were tested as per the standard operating procedure at respective ICMR-FoodNet laboratories and MycoNet laboratory at Assam. Samples were collected under six broad categories: milk products, edible insects, non-vegetarian, legumes/cereals, veggies, and alcoholic beverages. Data compilation was done centrally through a digital data portal. Quality assurance was done by the ICMR-National Institute for Research in Bacterial Infections (NIRBI), Kolkata. A total of 1227 samples were collected, among which 78 samples (6.8%) were positive for enteric pathogens, with Bacillus cereus being the most prevalent one (n = 59). Furthermore, 71 fungal isolates were detected from different food categories. The most common mycotoxin-producing fungal genera include Aspergillus [A. fumigatus (n = 7)], Rhizopus [R. arrhizus (n = 13)], and Penicillium (n = 2). Traditional foods have immense social, and cultural value and popularity among locals. However, processing, fermentation, and preservation of these foods without any preservatives and refrigerators, increases the possibility of contamination and growth by pathogenic organisms. It is crucial to understand the contamination risk involved during preparation so that the safety of these traditional foods can be ensured and local delicacies can be relished without any fear of foodborne infections and outbreaks, particularly when consumed by masses during festivals.

Food and waterborne outbreaks are a neglected public health problem in India. However, it is important to identify the source of infection and the causative pathogen to curb the outbreak quickly and minimize mortality and morbidity. A retrospective descriptive study was conducted with a line list of 130 diarrheal cases. Epidemiological investigation and laboratory investigation were done. Data were collected from hospital case report forms as well as interviewed affected cases. A case of acute diarrheal disease was reported among the people in the village with abdominal pain, vomiting, and diarrhea from December 31, 2022 to January 3, 2023. Out of a total of 130 recorded cases, 33 stool samples were collected and were positive for Enteroaggregative Escherichia coli, Shigella flexneri 3a, and Shigella sonnei by cultural and molecular tests. The presumptive fecal pollution indicator assay indicated high coliform counts in the water samples (most probable number [MPN]-05) and the presence of Escherichia coli. The identified pathogens showed susceptibility to gentamicin and meropenem. People who used public drinking water were found to be infected with acute diarrheal disease (ADD). Quick identification of the causative pathogens and their antimicrobial resistance pattern helped correct antibiotic prescriptions and quick recovery of the patients without any deaths. Thus, a timely implementation of food and waterborne outbreak investigation is crucial to saving lives and preventing the spread of infection.

Background: Food safety is a global concern, which is often underestimated owing to challenges in investigating foodborne diseases. These challenges arise from the increased globalization of the food trade, advancements in agricultural practices, and shifts in environmental factors. In North-East India, common diarrheal outbreaks from fermented foods pose significant health risks. Despite these challenges, systematic data on foodborne pathogens is lacking in India, highlighting a crucial gap in understanding food safety issues. Objective: The aim of this research protocol is to establish an integrated surveillance system to identify enteric pathogens circulating within humans, food animals, and the environment through a health approach in North-East India, and to conduct outbreak investigations. Methods: The Indian Council of Medical Research (ICMR) initiated a surveillance study across all 8 North-East states in India, employing a centralized digital database for data collation. The project aims to enhance the infrastructure for microbial culture, antibiotic sensitivity testing, and molecular epidemiological studies. The study involves laboratory-based surveillance of foodborne pathogens in market foods, hospitalized diarrheal patients, poultry and animal farms, slaughterhouses, butcher shops, and diarrheal outbreaks. A standardized case report form ensures consistent data collection of age, sex, signs, symptoms, and admission dates for diarrheal cases. Stool and rectal swabs will undergo testing for pathogen identification and antimicrobial resistance. Similarly, samples of market foods, food animals, and the environment will be collected. Outbreaks confirmed by the Integrated Disease Surveillance Project (IDSP) will be thoroughly investigated following standardized guidelines. Results: In phase I, 5 surveillance centers were established across 4 states (ie, Assam [Dibrugarh and Guwahati], Tripura, Sikkim, and Arunachal Pradesh) in 2020. Following an interim phase I data assessment and the successful establishment of a streamlined system for data procurement, investigation, recording, and analysis, along with the implementation of regular training and monitoring programs, phase II expansion was initiated in 2023-24. This includes the addition of 7 more centers (including 3 veterinary centers) in the remaining 4 states (ie, Manipur, Meghalaya, Mizoram, and Nagaland), eventually covering the entire North-Eastern Region of India. Conclusions: Food and waterborne diseases are a constant public health problem in many countries. Key challenges to the enhancement of food safety policy include the paucity of systematic data and awareness. With this background, ICMR’s initiative is the first systematic surveillance study in the country to adopt a single health approach. Data obtained from this project will help to understand the risk of acquiring food and waterborne pathogens, their transmission pathways, and antimicrobial resistance patterns. The scientific evidence generated through this project will be helpful in formulating and strengthening food safety policy and in initiating government programs to protect the health of the nation. International Registered Report Identifier (IRRID): DERR1-10.2196/56469