Foodborne Illness outbreaks in the Islamic Republic of Iran- How Portable Screening Tests Can Limit Exposure

2 November 2023

Abstract

Foodborne outbreaks in the Islamic Republic of Iran disproportionately affect many, such as young people and those living in rural or economically disadvantaged provinces. Iranians under 30 years of age face a more than 275% higher risk of experiencing a foodborne outbreak compared to those over 30.

Data shows incidence rates of foodborne disease outbreaks in various Iranian provinces exhibited significant variation through the years, though some indigent and or rural provinces consistently remained high-risk. Despite pre-existing food surveillance measures within Iran, some rural provinces reported higher outbreaks in 2011 compared to the national average, and then again in 2016.

The capacity for diagnosing the causes of these outbreaks within the country is limited. Issues of climate change, healthcare infrastructure, difficulty attracting foreign medical professionals, and economical disadvantage are all detrimental, and present in most of these provinces.

Foodborne outbreak surveillance has proven to be beneficial for primary healthcare in Iran, and available, cost effective, and simple testing will only help. Our project targets these at-risk groups and showcases the benefit of distributing field-deployable screening tests for food contaminants, as well as bettering epidemic identification intelligence methods in Iran.

Background

Foodborne illnesses present a significant challenge in Iran, underscoring the need for effective detection and surveillance measures. Data from Iran highlights the necessity for comprehensive food safety monitoring, with a particular focus on vulnerable populations, including rural communities, women, and young individuals. This issue is pervasive in both rural and urban areas, as evidenced by Tehran, where data reveals the presence of foodborne agents in various food items, including sweets and greens, yet rural areas have several force multipliers which disadvantage them. 

2006-2011 Data

Between 2006 and 2011, Iran's population witnessed an average annual increase of 722,908 individuals.[1] During this same period, the incidence of foodborne diseases rose each year, surpassing the rate of population growth. The prevalence of outbreaks per 100,000 people increased progressively:[2]

●      2006: 0.075 per 100,000 people

●      2007: 0.153 per 100,000 people

●      2008: 0.326 per 100,000 people

●      2009: 0.359 per 100,000 people

●      2010: 0.723 per 100,000 people

●      2011: 1.381 per 100,000 people [3]

The number of hospitalizations and deaths fluctuated over the years.[4] Notably, in 2011, Khuzestan, Kermanshah, and Qazvin provinces experienced a higher number of outbreaks than the national average, despite their varied climates.[5][6]

Part 1, Chapter b: Common Toxins/Bacteria

E. coli, Shigella, Hepatitis A, and Vibrio cholera were the predominant pathogens in human samples, while E. coli, Staphylococcal toxin, Shigella, and Salmonella were common contaminants in food samples.[7]

Effects on Youth

This dataset indicates a disproportionate impact on younger individuals, with those aged 0-15 years being approximately 39.12% more susceptible to foodborne outbreaks compared to those aged 15-30 years.[8] Furthermore, individuals aged 15-30 years face approximately 58.24% higher odds of contracting foodborne diseases than those over the age of 30.[9] Notably, Iranians aged 0-30 years are at significantly higher risk, being 275.83% more prone to foodborne disease outbreaks than their older counterparts.[10]

Additionally, women and individuals in rural areas were shown to be at elevated risk.[11]

2015-2016 Data

In 2015-2016, Qazvin and Kermanshah continued to report foodborne outbreaks above the national average, while Khuzestan remained high.[12] Zanjan and Mazandaran provinces surpassed and exceeded the national average, respectively.[13] Common pathogens included Escherichia Coli, Shigella, Entamoeba Histolytica, Salmonella, Hepatitis A virus, and Vibrio NAG, with clinical diagnosis indicating the presence of Staphylococcus Toxin, Rotaviruses, Hepatitis A virus, and Adenovirus.[14]

Rural areas again experienced a high level of outbreaks (56.1%).[15]

Provinces Compared, 2006-2011 vs. 2015-2016 Data Sets

The incidence rates of foodborne disease outbreaks varied significantly across different provinces in Iran during both timeframes. Some provinces that were high-risk in 2006-2011 experienced lower risks in 2015-2016 and vice versa.[16][17]

Effects on Rural Areas

Despite Iran's expected continuing urbanization, a substantial portion of the population resides in rural areas.[18] [19]Cities have faced challenges due to rapid urban growth and development.[20] Healthcare infrastructure, especially in rural regions, is limited. The consistent high-risk provinces, such as Khuzestan, Kermanshah, and Qazvin, witnessed multiple breaches of the national average outbreak incidence rate, and these higher risk, sometimes rural provinces lack adequate healthcare infrastructure,[21] and suffer from low density in  healthcare professionals countrywide and more so in these provinces,[22] and the success of having and getting Iranian medical professionals to work in rural areas has been modest.[23] Legally-required externships for recent doctoral graduates who serve in rural, government-run clinics further temporarily provide relief for  the issue.[24]

Conclusion

Rural areas are particularly vulnerable to foodborne health issues, and climate change and population growth are expected to worsen the situation.[25] Diagnosis and healthcare infrastructure in these areas are limited.[26] Given these challenges, the introduction of simple, cost-effective testing methods, such as rapid screening kits, could significantly benefit Iran, especially in rural regions.

Remedy of data sharing

Information sharing in the etiological field will have benefits. Hepatitis A was referenced to be present in Iran in the 2006-2011 sample, but not in many other places in the world.[27] Inversely - Some countries may have more data on certain etiological agents which could benefit Iranian foodborne disease identification, which, in the 2006-2011, prompted researchers to suggest information sharing between countries.[28]

Remedy of Rapid Screening for Safe Food in Iran

Surveying foodborne agents has been beneficial, and deploying kits matching the increasing susceptibility to these pathogens can partially replace the need for fully equipped laboratories. The Rapid Screening for Safe Food project can significantly aid Iran by providing a potent tool for detecting and addressing foodborne illnesses, particularly among the youth and in regions with limited healthcare infrastructure, reliably, cheaply, and rapidly.[29]

Nuclear Techniques for Addressing Foodborne Illness in Iran

In addition to rapid screening methods, nuclear techniques such as mass spectrometry tools like MALDI-TOF-MS[30]  and isotope-assisted proteomics[31] can play a pivotal role in addressing Iran's foodborne illness issue. These techniques can offer accurate and timely pathogen detection, which can enhance food safety across the countries and can be implemented in places, like Tehran and or Qazvin which have noted pre-made foods to have contained foodborne etiological agents in concerning quantities, with links to improper sanctuary conditions and or other ability for such agents to be unknowingly introduced into premade food.[32] [33] [34]

By improving monitoring and control of foodborne illnesses, these methods can mitigate the impact of outbreaks and enhance public health.

[1] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[2] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[3] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[4] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[5] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[6] Najafi , M. S., & Alizadeh, O. (n.d.). Climate zones in Iran. (PDF) Climate zones in Iran. https://www.researchgate.net/publication/373196691_Climate_zones_in_Iran

[7] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[8] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[9] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[10] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[11] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[12] Delavari, S., Arab, M., Rashidian, A., Nedjat, S., & Souteh, R. G. (2016a, November). A qualitative inquiry into the challenges of medical education for retention of general practitioners in rural and underserved areas of Iran. Journal of preventive medicine and public health = Yebang Uihakhoe chi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5160132/

[13] Delavari, S., Arab, M., Rashidian, A., Nedjat, S., & Souteh, R. G. (2016, November). A qualitative inquiry into the challenges of medical education for retention of general practitioners in rural and underserved areas of Iran. Journal of preventive medicine and public health = Yebang Uihakhoe chi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5160132/

[14] Delavari, S., Arab, M., Rashidian, A., Nedjat, S., & Souteh, R. G. (2016, November). A qualitative inquiry into the challenges of medical education for retention of general practitioners in rural and underserved areas of Iran. Journal of preventive medicine and public health = Yebang Uihakhoe chi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5160132/

[15] Delavari, S., Arab, M., Rashidian, A., Nedjat, S., & Souteh, R. G. (2016, November). A qualitative inquiry into the challenges of medical education for retention of general practitioners in rural and underserved areas of Iran. Journal of preventive medicine and public health = Yebang Uihakhoe chi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5160132/

[16] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[17] Delavari, S., Arab, M., Rashidian, A., Nedjat, S., & Souteh, R. G. (2016, November). A qualitative inquiry into the challenges of medical education for retention of general practitioners in rural and underserved areas of Iran. Journal of preventive medicine and public health = Yebang Uihakhoe chi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5160132/

[18] United Nations. (n.d.). World urbanization prospects - population division. United Nations. https://population.un.org/wup/Country-Profiles/

[19] Mohebbifar, R., Akbarirad, F., Ranjbar, M., & Rafiei, S. (2019, August 16). What do Iranian general practitioners expect from family physician contracts?. Family medicine and community health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910745/

[20] (PDF) spatial-geographical analysis of urbanization in Iran - Researchgate. (n.d.-b). https://www.researchgate.net/publication/349833615_Spatial-geographical_analysis_of_urbanization_in_Iran

[21] Shojaei, P., Bordbar, N., Ghanbarzadegan, A., Najibi, M., & Bastani, P. (2020, February 3). Ranking of Iranian provinces based on healthcare infrastructures: Before and after implementation of health transformation plan. Cost effectiveness and resource allocation : C/E. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998310/

[22] Islamic Republic of Iran - emro regional health observatory. (n.d.). https://rho.emro.who.int/sites/default/files/Profiles-briefs-files/IRN-WHOEMHRH654E-eng.pdf

[23] Mirmoeini, S. M., Marashi Shooshtari, S. S., Battineni, G., Amenta, F., & Tayebati, S. K. (2019, December 13). Policies and challenges on the distribution of specialists and subspecialists in rural areas of Iran. Medicina (Kaunas, Lithuania). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955942/#:~:text=Physicians%20are%20unsuitably%20distributed%20in,for%20the%20Iranian%20Health%20Ministry.

[24] Islamic Parliament Research Center Of The Islamic Republic Of IRAN. (n.d.). مرکز پژوهشها - لایحه قانونی خدمت نیروی انسانی درمانی و بهداشتی. https://web.archive.org/web/20190629234727/http://rc.majlis.ir/fa/law/show/98448

[25] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[26] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[27] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[28] Masoumi Asl, Hossein, et al. “Surveillance for Foodborne Disease Outbreaks in Iran, 2006-2011.” Medical Journal of the Islamic Republic of Iran, U.S. National Library of Medicine, 3 Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4764277/. Accessed 01 Nov. 2023.

[29] IAEA. (2021, December 16). Rapid screening for Safe Food. IAEA. https://www.iaea.org/projects/crp/d52045

[30] Franco-Duarte, R., Černáková, L., Kadam, S., Kaushik, K. S., Salehi, B., Bevilacqua, A., Corbo, M. R., Antolak, H., Dybka-Stępień, K., Leszczewicz, M., Relison Tintino, S., Alexandrino de Souza, V. C., Sharifi-Rad, J., Coutinho, H. D. M., Martins, N., & Rodrigues, C. F. (2019, May 13). Advances in chemical and biological methods to identify microorganisms-from past to present. Microorganisms. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560418/

[31] IAEA. (2021, October 5). New CRP: Nuclear techniques to support risk assessment of biotoxins and pathogen detection in food and related matrices (D52044). International Atomic Energy Agency. https://www.iaea.org/newscenter/news/new-crp-nuclear-techniques-to-support-risk-assessment-of-biotoxins-and-pathogen-detection-in-food-and-related-matrices-d52044

[32] IAEA. (2021, October 5). New CRP: Nuclear techniques to support risk assessment of biotoxins and pathogen detection in food and related matrices (D52044). International Atomic Energy Agency. https://www.iaea.org/newscenter/news/new-crp-nuclear-techniques-to-support-risk-assessment-of-biotoxins-and-pathogen-detection-in-food-and-related-matrices-d52044

[33] Azimirad M;Nadalian B;Alavifard H;Negahdar Panirani S;Mahdigholi Vand Bonab S;Azimirad F;Gholami F;Jabbari P;Yadegar A;Busani L;Asadzadeh Aghdaei H;Zali MR; (n.d.). Microbiological survey and occurrence of bacterial foodborne pathogens in raw and ready-to-eat green leafy vegetables marketed in Tehran, Iran. https://pubmed.ncbi.nlm.nih.gov/34365294/

[34] Pakbin, B., Amani, Z., Rahimi, Z., Najafi, S., Familsatarian, B., Khakpoor, A., Brück, W. M., & Brück, T. B. (2023a, October 2). Prevalence of foodborne bacterial pathogens and antibiotic resistance genes in sweets from local markets in Iran. https://www.mdpi.com/2304-8158/12/19/3645