Bacteria and Poisonous Plants: Foodborne Disease Outbreak in Guangxi, South China (2010-2016) PDF

Li et al. BMC Public Health (2018) 18:519 https://doi.org/10.1186/s12889-018-5429-2 RESEARCH ARTICLE Open Access Bacteria and poisonous plants were the primary causative h...

Li et al. BMC Public Health (2018) 18:519 https://doi.org/10.1186/s12889-018-5429-2 RESEARCH ARTICLE Open Access Bacteria and poisonous plants were the primary causative hazards of foodborne disease outbreak: a seven-year survey from Guangxi, South China Yongqiang Li1,2†, Yaling Huang3,4,5†, Jijun Yang2, Zhanhua Liu7, Yanning Li8, Xueting Yao7, Bo Wei2, Zhenzhu Tang7, Shidong Chen2, Decheng Liu9, Zhen Hu2, Junjun Liu8, Zenghui Meng2, Shaofa Nie1 and Xiaobo Yang4,5,6* Abstract Background: Foodborne diseases are a worldwide public health problem. However, data regarding epidemiological characteristics are still lacking in China. We aimed to analyze the characteristics of foodborne diseases outbreak from 2010 to 2016 in Guangxi, South China. Methods: A foodborne disease outbreak is the occurrence of two or more cases of a similar foodborne disease resulting from the ingestion of a common food. All data are obtained from reports in the Public Health Emergency Report and Management Information System of the China Information System for Disease Control and Prevention, and also from special investigation reports from Guangxi province. Results: A total of 138 foodborne diseases outbreak occurred in Guangxi in the past 7 years, leading to 3348 cases and 46 deaths. Foodborne disease outbreaks mainly occurred in the second and fourth quarters, and schools and private homes were the most common sites. Ingesting toxic food by mistake, improper cooking and cross contamination were the main routes of poisoning which caused 2169 (64.78%) cases and 37 (80.43%) deaths. Bacteria (62 outbreaks, 44.93%) and poisonous plants (46 outbreaks, 33.33%) were the main etiologies of foodborne diseases in our study. In particular, poisonous plants were the main cause of deaths involved in the foodborne disease outbreaks (26 outbreaks, 56.52%). Conclusions: Bacteria and poisonous plants were the primary causative hazard of foodborne diseases. Some specific measures are needed for ongoing prevention and control against the occurrence of foodborne diseases. Keywords: Foodborne diseases, Foodborne disease outbreaks, Epidemiology Background Organization (WHO) in 2007, estimated that 31 foodborne Foodborne diseases have been an issue for all societies and hazards caused 600 million foodborne illnesses and 420,000 are a continuing public health problem. Annually, one- deaths in 2010. In addition, the global burden of food- third of people worldwide are infected by foodborne patho- borne disease by these 31 hazards was 33 million disability- gens. The Foodborne Disease Burden Epidemiology Ref- adjusted life years (DALYs) in 2010. Therefore, more atten- erence Group (FERG), established by the World Health tion should be focused on foodborne disease. In developing countries, such as China, food safety re- * Correspondence: [email protected] mains a social health problem, playing a crucial role in † Equal contributors 4 Center for Genomic and Personalized Medicine, Guangxi Medical University, public health , and it is directly related to social stabil- Nanning, Guangxi, China ity. From 2001 to 2010, 5021 outbreaks of foodborne 5 Guangxi Collaborative Innovation Center for Genomic and Personalized disease were reported in China, causing 140,101 illnesses Medicine, Nanning, Guangxi, China Full list of author information is available at the end of the article and 1427 deaths. From 2004 to 2013, the mortality © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Li et al. BMC Public Health (2018) 18:519 Page 2 of 8 rate of foodborne diseases was 1.9% in China. Major Public Health Emergency Report and Management In- sources of foodborne diseases in China include patho- formation System of the China Information System for genic microorganisms, toxic insects/food products and Disease Control and Prevention, and were summa- plants entering the food supply, and chemical contamin- rized from foodborne disease special investigation re- ation. A total of 371 outbreaks related to bacterial ports around Guangxi. A single outbreak was foodborne diseases were reported in China between reported on a food hygiene incident report card. The 2008 and 2010, and 20,062 cases and 41 deaths were in- card contains the number of cases and deaths, onset volved. Since 2000, a total number of 52 cases of date, outbreak areas and sites, implicated foods, con- mushroom poisoning due to Amanita exitialis have been tributing factors and causative hazards. Implicated reported, causing 20 deadths. foods were categorized as grains, meat and poultry, Foodborne diseases and diseases potentially transmit- seafood, eggs, dairy products, cakes and bakery prod- ted by food are investigated by the China Food and Drug ucts, vegetables, toxic insects/food products, poison- Administration (CFDA) in China. The CFDA conducts ous plants and others, which were not confirmed. surveillance in the Public Health Emergency Report and Contributing factors include material contamination Management Information System of the China Informa- and deterioration, equipment contamination, hand- tion System for Disease Control and Prevention. The ling contamination, improper cooking, cross contam- CFDA has monitored illness trends, detected outbreaks, ination, long preparation time, ingesting poisonous provided information about preventative measures, eval- food by mistake and deliberate poisoning. Causative uated the efficacy of intervention efforts and carried out hazards, such as bacteria, poisonous plants, chemical work based on the Food Safety Law since 2009. agents and toxic insects/food products, were con- Although the surveillance system for foodborne diseases firmed by laboratory tests and epidemiological inves- and the law on food safety have been effective in China, tigation. Factors which failed to be detected by foodborne diseases remain a severe public health problem, existing laboratory conditions but confirmed by epi- and few studies or data analyses have focused on it. In this demiological investigation were classified as “uncon- paper, we investigated the prevalence and epidemiological firmed”. The outbreak areas were categorized as characteristics of foodborne disease outbreaks from 2010 village, town and city. The outbreak sites were cate- to 2016 in Guangxi, and provided evidence for the on- gorized as canteens, private homes, schools, restau- going prevention and control against foodborne diseases. rants and delicatessens. All the laboratory test methods were performed in accordance with national Methods methods of food hygienic analysis. Definitions Foodborne disease is defined as any disease of an in- Statistical analysis fectious or toxic nature caused by consumption of All analyses were performed using SPSS statistical program, food , with clinical symptoms, such as nausea, version 16.0. A chi-square test was used to compare differ- vomiting, abdominal pain, diarrhea, other gastrointes- ences in death among quarters and areas, and causative tinal symptoms or nerve symptoms of poisoning. hazard. The Bonferroni test was used for pairwise compari- Food poisoning cases are reported on the basis of as- son of death. A nominal two-sided P value less than 0.05 sessment by physicians at the hospital and confirmed was considered to indicate statistical significance. A two- by epidemiologists from local Centers for Disease sided P´ value less than 0:05 (k represents the number of C2 Control (CDC). A foodborne disease outbreak is the k occurrence of two or more cases of similar foodborne groups) was considered to indicate statistical significance in disease resulting from the ingestion of a common the Bonferroni test. All tables and figures were devised food. In this study, we analyzed only outbreaks that using Microsoft Excel software, version 2007 and GraphPad were caused by diseases of toxic nature (vs. Prism, version 5.01, respectively. infectious). We divided a year into four quarters: the first quarter Results (January, February, March), the second quarter (April, General characteristics May, June), the third quarter (July, August, September) From 2010 to 2016, 138 foodborne disease outbreaks oc- and the fourth quarter (October, November, December). curred, with a mean of 19.7 (ranging from 11 to 29) foodborne disease outbreaks being reported annually Data collection (Table 1). A total of 3348 cases and 46 deaths were in- The official statistics regarding foodborne disease out- volved in foodborne disease outbreak during those 7 breaks reported between 2010 and 2016 in Guangxi years, with 24.26 cases per outbreak. The morbidity of were downloaded from the information reported in the foodborne disease outbreak ranged from 0.63 to 1.59 Li et al. BMC Public Health (2018) 18:519 Page 3 of 8 Table 1 Number of outbreaks, cases and deaths by year, Guangxi, South China, 2010–2016 Year No.(%) of outbreaks No.(%) of cases No.(%) of deaths Morbidity a (1/100000) Case fatality rate (%) 2010 21 (15.22) 444 (13.26) 11 (23.91) 0.96 2.48 2011 29 (21.01) 738 (22.04) 13 (28.26) 1.59 1.76 2012 16 (11.59) 343 (10.24) 6 (13.04) 0.73 1.75 2013 11 (7.97) 296 (8.84) 3 (6.52) 0.63 1.01 2014 21 (15.22) 625 (18.67) 2 (4.35) 1.31 0.32 2015 21 (15.22) 409 (12.22) 8 (17.39) 0.85 1.96 2016 19 (13.77) 493 (14.73) 3 (6.52) 1.03 0.61 total 138 3348 46 1.02 1.37 a The morbidity were calculated basing on the Guangxi population reported in Guangxi Statistical Year book cases per 100,000 people, and the case fatality rates Distribution of areas and sites ranged from 0.32 to 2.48%. The outbreaks were likely to occur in villages and towns. As shown in Table 2, the proportion of outbreaks and Time distribution cases in villages and towns were higher than that in cit- The lowest number of outbreaks (28 of 138, 20.29%) and ies. As for the occurring sites, the places of outbreaks cases (704 of 3348, 21.03%) occurred in the first quarter were mainly located in schools (59 of 138, 42.75%) and compared to the other three quarters (Table 2). The case private homes (45 of 138, 32.61%). The cases tended to fatality rate in the third quarter (0.42%) was the lowest, be concentrated in schools (1600 of 3348, 47.79%), while it was the highest in the fourth quarter (1.87%). whereas the deaths mainly occurred in private homes The outbreaks mainly occurred in January, April, No- (36 of 46, 78.26%) (Table 3). vember, October, May and July, and in February the number of cases was the lowest during months investi- Categories of poisoning food and transmission routes gated. In addition, the case fatality was the highest in Up to ten kinds of food were found to be related to May (Additional file 1). A significant difference was foodborne disease outbreaks. The top three were poison- found for death between the second and third quarters, ous plants (46, 33.33%), mixed food (39, 28.26%) as well and between the third and fourth quarters (p = 0.018). as meat and poultry (15, 10.87%). In particular, Table 2 Number of outbreaks, cases and deaths of quarters, areas and causative hazard, Guangxi, South China, 2010–2016 a No.(%) of outbreaks No.(%) of cases No.(%) of deaths Case fatality rate (%) p value b Quarters 0.008 First 28 (20.29) 704 (21.03) 9 (19.57) 1.28 Second 39 (28.26) 963 (28.76) 19 (41.30) 1.97 Third 31 (22.46) 931 (27.81) 4 (8.70) 0.43 Fourth 40 (28.99) 750 (22.40) 14 (30.43) 1.87 c Areas 0.001 Village 50 (36.23) 1202 (35.90) 20 (43.48) 1.66 Town 50 (36.23) 1158 (34.59) 23 (50.00) 1.99 City 38 (27.54) 988 (29.51) 2 (6.52) 0.30 Causative hazard d < 0.001 Bacteria 62 (44.93) 2123 (63.41) 6 (13.04) 0.28 Chemical agents 9 (6.52) 131 (3.91) 8 (17.39) 6.11 Toxic insects/food products 3 (2.17) 15 (0.45) 3 (6.52) 20.00 Poisonous plants 46 (33.33) 711 (21.24) 26 (56.52) 3.66 Factors unconfirmed 18 (13.04) 368 (10.99) 3 (6.52) 0.82 Total 138 3348 46 1.02 a Differences in death among quarters, areas, and causative hazard were compared by Chi-Square test. b Differences in death were significant in the comparison of the second and the third quarter, and the comparison the third and the fourth quarter (p = 0.018). c Differences in death were significant in all areas pairwise comparison (p = 0.017) except comparison of village and town (p =.0558). d Differences in death were significant in all causative hazard pairwise comparison (p = 0.018) except comparison of chemical agents and toxic insects/food products (p = 0.053), and chemical agents and poisonous plants (p = 0.191) Li et al. BMC Public Health (2018) 18:519 Page 4 of 8 Table 3 Number of outbreaks, cases and deaths by site, Guangxi, South China, 2010–2016 Site No.(%) of outbreaks (n = 138) No.(%) of cases (n = 3348) No.(%) of deaths (n = 46) Case fatality rate (%) Canteens 7 (5.07) 106 (3.17) 0 (0.00) 0.00 Private homes 45 (32.61) 814 (24.31) 36 (78.26) 4.42 Schools 59 (42.75) 1600 (47.79) 0 (0.00) 0.00 Restaurants 10 (7.25) 407 (12.16) 0 (0.00) 0.00 Delicatessens 9 (6.52) 299 (8.93) 0 (0.00) 0.00 Others a 8 (5.80) 122 (3.64) 10 (21.74) 8.20 a Other sites include construction sites and field poisonous plants were the main cause of death involved were the main factors for deaths (Table 6). Notably, in the foodborne disease outbreaks (26, 56.52%) (Table 4). there were 30 outbreaks in which the causative hazard The transmission routes of foodborne disease outbreaks could not be found, involving 719 cases and 9 deaths. were diverse. We found that ingesting poisonous food by Significant differences were found in the deaths of the mistake, improper cooking methods and cross contam- five causative hazards (p < 0.001), and deaths caused by ination were the main transmission routes, causing 2169 toxic insects/food products was higher than those (64.78%) infection cases and 37 (80.43%) deaths. Ingest- caused by bacteria and poisonous plants. ing poisonous food by mistake was the main cause of death (35 of 46, 76.09%), and deliberate poisoning caused a high case fatality rate (50.00%) (Table 5). Discussion Suspicious food, contributing outbreak factors and spe- Causative hazard cific causative hazard are the most crucial elements of The causative hazards were classified into bacteria, poi- foodborne disease outbreaks. If the linkages among them sonous plants, chemical agents and toxic insects/food were found and appropriate measures were taken, the products. Bacteria (62 of 138, 44.93%) and poisonous number of foodborne disease outbreaks could be con- plants (46, 33.33%) were the first and second factors for trolled. In the present study, we investigated 138 food- foodborne disease outbreaks, respectively (Table 2). In borne disease outbreaks from 2010 to 2016 in Guangxi, addition, the main species of bacteria contributing to South China; our data showed that the rates of food- foodborne disease outbreaks were Salmonella, Vibrio borne disease outbreaks that occurred in the second and parahaemolyticus and Staphylococcus aureus (Fig. 1). fourth quarters were higher than those in the first and Tung oil fruit or tung oil, Gelsemium elegans and toxic third quarters. The foodborne disease outbreaks were mushroom were the primary sources of poisoning from likely to occur in schools. The main contributing factors poisonous plants (Fig. 2). Contaminations by Burkhol- of foodborne disease outbreaks included ingesting poi- deria gladioli (6 of 46, 13.04%), toxic mushroom (5 of sonous food by mistake, improper cooking and cross 46, 10.87%) and Gelsemium elegans (17 of 46, 36.96%) contamination, and the main causative hazard of Table 4 Number of outbreaks, cases and deaths by different kinds of food, Guangxi, South China, 2010–2016 Food No.(%) of outbreaks (n = 138) No.(%) of cases (n = 3348) No.(%) of deaths (n = 46) Case fatality rate (%) Grains 8 (5.80) 164 (4.90) 6 (13.04) 3.66 Meat and poultry 15 (10.87) 513 (15.32) 0 (0.00) 0.00 Seafood 5 (3.62) 141 (4.21) 0 (0.00) 0.00 Eggs 2 (1.45) 54 (1.61) 0 (0.00) 0.00 Dairy products 1 (0.72) 15 (0.45) 0 (0.00) 0.00 Cakes and bakery products 4 (2.90) 94 (2.81) 0 (0.00) 0.00 Vegetables 2 (1.45) 51 (1.52) 0 (0.00) 0.00 Toxic insects/food products 3 (2.17) 15 (0.45) 3 (6.52) 20.00 Poisonous plants 46 (33.33) 711 (21.24) 26 (56.52) 3.66 Mixed food a 39 (28.26) 1238 (36.98) 4 (8.70) 0.32 b Others 13 (9.42) 352 (10.51) 7 (15.22) 1.99 a Mixed Food was identified as at least two kinds of food involved in a food poisoning incident b Other kind of food include frog and the food we cannot confirm Li et al. BMC Public Health (2018) 18:519 Page 5 of 8 Table 5 Number of outbreaks, cases and deaths by different ways of poisoning, Guangxi, South China, 2010–2016 Contributing factors No.(%) of outbreaks (n = 98) No.(%) of cases (n = 2446) No.(%) of deaths (n = 35) Case fatality rate (%) Material contamination and deterioration 14 (10.14) 317 (9.47) 6 (13.04) 1.89 Equipment contamination 2 (1.45) 99 (2.96) 0 (0.00) 0.00 Handlers contaminating 2 (1.45) 118 (3.52) 0 (0.00) 0.00 Improper cooking 27 (19.57) 849 (25.36) 2 (4.35) 0.24 Cross contamination 20 (14.49) 747 (22.31) 0 (0.00) 0.00 Long preparation time 9 (6.52) 232 (6.93) 1 (2.17) 0.43 Ingesting poisonous food by mistake 45 (32.61) 573 (17.11) 35 (76.09) 6.11 Deliberate poisoning 1 (0.72) 2 (0.06) 1 (2.17) 50.00 Others a 18 (13.04) 411 (13.04) 1 (2.17) 0.24 a Other sources of poisoning include using the contaminated water and the sources we cannot identify foodborne disease outbreaks were bacteria and poison- measures, such as strengthening public awareness and ous plants in Guangxi. supervision of food safety, are needed to prevent food- During the five-year reporting period, the number of borne disease outbreaks in these months in which food- foodborne disease outbreaks, cases and deaths decreased borne disease outbreaks occurred frequently. compared with the period from 2005 to 2009 in Guangxi Li found that most deaths from foodborne disease. This suggests that the enhanced surveillance of outbreaks took place in private homes between 2002 and food poisoning had an effect on food safety since the 2011 in China. In accordance with this current study, new law was established in 2009. The new law was fo- private homes were the most severely afflicted foodborne cused on strengthening food safety risk monitoring and disease outbreaks, where 78.26% of deaths occurred. assessment, and punishment for violations was more This finding shows that it is extremely important for the stringent than before. From 2010 to 2016, the number of public health authorities to teach the public population foodborne disease outbreaks reported annually fluctu- how to save themselves in case poisoning occurs at ated substantially, and the number of outbreaks in 2014 home. In addition, we also found that approximately to 2016 was higher than that in 2012 and 2013. This three-quarters of outbreaks occurred in rural areas and might be due to the reformation of the Guangxi Supervi- towns, especially at schools in remote areas. Good envir- sion and Management System for Food and Drugs in onmental hygiene can help us to prevent many illnesses October 2013, which brought about a change in supervi- caused by infection from noxious pathogens, and can sion staff and departments of catering services. prevent noxious pathogens contaminating food. There- Our result was in line with previous studies, which fore, if supervision of environmental hygiene is im- showed that foodborne disease outbreaks were likely to proved, poisoning may be controlled. occur in warm months [4, 11, 12]. Foodborne disease Improper practices of food handlers in hand, equipment outbreaks were related to changes in weather. The and utensil hygiene; maintenance of temperature of food natural environment in Guangxi is subtropical monsoon ready for consumption; cooking temperature; and thawing weather, and this warm and humid weather is conducive relates directly to foodborne disease and are the main to bacteria and herbal medicine growth, which is medi- cause of foodborne disease outbreaks [15–17]. In this cine made from plants and used to prevent or treat dis- study of 138 foodborne disease outbreaks, improper ease or promote health. Therefore, some special Fig. 1 Number of outbreaks of the bacterial causative hazard, Fig. 2 Number of outbreaks of the toxic plant causative hazard, Guangxi, South China, 2010–2016 Guangxi, South China, 2010–2016 Li et al. BMC Public Health (2018) 18:519 Page 6 of 8 Table 6 Number of cases and deaths by different Causative Shigella spp.. In their study found that norovirus, hazard, Guangxi, South China, 2010–2016 enteropathogenic e.coli, V. cholerae, and Shigella spp. Causative hazard No.(%) of No.(%) of were responsible for large numbers of deaths among the cases deaths diarrheal diseases and Salmonella Typhi, hepatitis A Bacteria 2123 (63.41) 6 (13.04) virus, invasive infections due to non-typhoidal S. enter- Burkholderia gladioli 11 (0.33) 6 (13.04) ica and Salmonella Paratyphi A were responsible for the Salmonella 735 (21.95) 0 (0.00) most deaths among the extra-intestinal enteric diseases. Vibrio para haemolyticus 375 (11.20) 0 (0.00) In this study, which focused only on outbreaks of food- borne disease of toxic nature (vs. infectious), we found Staphylococcus aureus 128 (3.82) 0 (0.00) that Salmonella, Vibrio para haemolyticus, Staphylococ- Bacillus cereus 113 (3.38) 0 (0.00) cus aureus, chemical agents, and tung oil fruit or tung Pathogenic E.coli 108 (3.23) 0 (0.00) oil were responsible for most cases. In addition, poison- Shigella 81 (2.42) 0 (0.00) ous plants were the leading cause of death. We did not Enteroadhesive E.Coli 25 (0.75) 0 (0.00) detect Campylobacter in all the samples. As is known, Mixed bacteria mentioned above 284 (8.48) 0 (0.00) the relative frequency of foodborne disease depends strongly on geography, local diet, sanitary conditions Others 263 (7.86) 0 (0.00) and general public health, among many other factors. Chemical agents 131 (3.91) 8 (17.39) The main reason for the differences in foodborne haz- Fluoroacetamide 2 (0.06) 2 (4.35) ards between WHO and our study may be a response to Tetramine 7 (0.21) 2 (4.35) the local diet. In China, dairy foods, the main vehicles Sulfur dioxide and dehydroacetic 83 (2.48) 0 (0.00) for Campylobacter, accounted less but frequently in acid United States. In China, people generally believe Nitrite 18 (0.54) 0 (0.00) that wild-harvested products, including mushrooms, Others 21 (0.63) 4 (8.70) have high nutritional and medicinal values and the risky behavior of collecting and consuming wild plants (such Toxic insects/food products 15 (0.45) 3 (6.52) as poisonous mushroom, Gelsemium elegans and tung Toxic honey 11 (0.33) 2 (4.35) oil fruit) happens mostly in remote districts in house- Mylabris cichorii 4 (0.12) 1 (2.17) hold clusters. Therefore, increasing public aware- Poisonous plants 711 (21.24) 26 (56.52) ness about food safety of poisonous plants is an Toxic mushroom 52 (1.55) 5 (10.87) important elements of preventing and controlling future Cassava 8 (0.24) 2 (4.35) foodborne disease outbreak. Our study showed that public awareness about food Tung oil fruit or tung oil 315 (9.41) 0 (0.00) safety of poisonous plant, hand hygiene of handlers and Dwarf bean 136 (4.06) 0 (0.00) policies about the interventions on foodborne illness Castor seed 21 (0.63) 0 (0.00) were important elements preventing and controlling Gelsemium elegans 112 (3.35) 17 (36.96) foodborne disease. Our findings might help in the devel- Others 67 (2.00) 2 (4.35) opment of a better foodborne disease monitoring system Factors unconfirmed 368 (10.99) 3 (6.52) based on the characteristics of Guangxi. From this, we Abbreviation: E.coli Escherichia coli can list high-risk foods, including meat, poultry and poi- sonous plants (e.g. tung oil, tung oil fruit and Gelse- cooking and cross contamination were the main causes mium elegans), to put forward appropriate measures for during meal preparation. Moreover, the lack of ability to prevention and control. Tung oil is rich in eleostearic identify poisonous food can easily cause poisoning, and acid. If eaten by mistake, symptoms of poisoning, such we found that ingesting poisonous food by mistake was as nausea, vomiting, abdominal pain, breathing difficul- the primary route of contracting foodborne disease out- ties, limb twitches, coma and laryngeal muscle spasm, breaks in Guangxi. Therefore, enhancing food safety appear within 2 h. Gelsemium elegans contains a variety knowledge and hygiene practices of handlers and improv- of alkaloids, such as gelsemine free base, which can in- ing the knowledge of residents about toxic food may be hibit the respiratory center and may eventually cause re- key points for ongoing supervision. spiratory center paralysis and death due to respiratory Bacterial food poisoning is a prevalent foodborne dis- failure. Improving the training and food safety awareness ease worldwide [18, 19]. WHO showed that the patho- of food handlers, enhancing the systems of food pro- gens resulting in the most foodborne cases were curement and inspection, strengthening the disinfection norovirus, Campylobacter spp., enterotoxigenic e.coli, of tableware and preventing improper handling and diarrheal disease due to non-typhoidal S. enterica, and cross contamination during food preparation should also Li et al. BMC Public Health (2018) 18:519 Page 7 of 8 be included. Moreover, skills of investigators, such as Funding their ability to investigate foodborne disease, identify This study was funded by the Guangxi Food and Drug Safety Project (GFD-201520), but played no role in the design of the study, analysis poisonous food, and their awareness about food safety and interpretation of data or in the writing of the manuscript. should be enhanced. Several limitations are necessary to be noted in the Availability of data and materials The data that support the findings of this study are available from the Public current study. First, we only discussed the epidemic of Health Emergency Report and Management Information System of the foodborne disease outbreaks of Guangxi, a province of China Information System for Disease Control and Prevention, and these China. Guangxi is one of five ethnic minority autono- data are not publicly available. mous regions in China, which includes twelve minorities Authors’ contributions and 46.82 million people in 2012. It is the only coastal XBY and YQL conceived the study and led the study design. XBY, YQL, YLH, autonomous region which is adjacent to the land and JJY, ZHL, YNL, XTY, ZH, JJL and ZHM collected and performed the statistical analysis together. BW, ZZT, SDC, DCL and SFN made substantial sea of Vietnam and the permanent venue of China- contributions to the data analysis and interpretation. XBY, YQL and YLH ASEAN Expo. Thus, we think it is necessary for us to wrote the manuscript. All the authors contributed to the interpretation of discuss the epidemic characteristics of foodborne disease the data, critical revision of the manuscript and read and approved the final manuscript. outbreaks and the security status of food in this autono- mous region. Second, 13.04% of outbreaks were found Ethics approval and consent to participate without a confirmed etiologic agent in our study. We All procedures performed in studies did not involve human participants and animals. The data used for our study were openly available in Public Health have made efforts to improve the collection of suspi- Emergency Report and Management Information System of the China cious food after foodborne disease outbreaks occurring Information System for Disease Control and Prevention and we received and the ability of food detection of our laboratory. Third, permission to use of this information in this paper from the office of Food Safety Commission. since some cases (e.g. mild acute gastro-enteritis) are self-curable and hardly recognized, reported or investi- Competing interests gated, it is susceptible to reporting bias. Fourth, the de- The authors declare that they have no competing interests. tection ability of the present clinical laboratories in Guangxi is relatively limited, and some pathogens are Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in perhaps not identified routinely. Finally, these findings published maps and institutional affiliations. might not be generalizable to other areas in China. Author details 1 Department of Epidemiology and Health Statistics, School of Public Health of Huazhong University of Science and Technology, Wuhan, Hubei, China. Conclusion 2 Guangxi Food and Drug Administration, Nanning, Guangxi, China. The primary causative hazard of foodborne disease out- 3 Department of Epidemiology and Health Statistics, School of Public Health breaks in Guangxi were bacteria and poisonous plants, of Guangxi Medical University, Nanning, Guangxi, China. 4Center for Genomic and Personalized Medicine, Guangxi Medical University, Nanning, Guangxi, and the contributing factors were ingesting poisonous China. 5Guangxi Collaborative Innovation Center for Genomic and food by mistake, improper cooking and cross contamin- Personalized Medicine, Nanning, Guangxi, China. 6Department of ation. Therefore, improving the detection of bacteria in Occupational Health and Environmental Health, School of Public Health of Guangxi Medical University, Shuangyong road, Nanning 530021, Guangxi, food, and the market supervision of poisonous plants China. 7Guangxi Zhuang Autonomous Region Center for Disease Control and and propaganda knowledge about food safety might be Prevention, Nanning, Guangxi, China. 8School of Information and helpful for us to control foodborne disease outbreaks. Management of Guangxi Medical University, Nanning, Guangxi, China. 9 Guangxi Zhuang Autonomous Region Health and Family Planning Commission, Nanning, Guangxi, China. Additional file Received: 12 April 2017 Accepted: 10 April 2018 Additional file 1: Table Number of outbreaks, cases and deaths by References month, Guangxi, South China, 2010–2016. (DOC 42 kb) 1. Food safety at risk in Asia and the Pacific. http://www.fao.org/Newsroom/ en/news/2004/43073/index.html. Accessed 24 May 2004. 2. Organization WH. 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