Foodborne Disease and Public Health: Summary of an Iranian-American Workshop (2008)

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Foodborne Disease and Public Health Carol West Suitor and Maria Oria, Rapporteurs Food and Nutrition Board Office for Central Europe and Eurasia Policy and Global Affairs Division 

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, N.W.  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. This study was supported by Agreement for Services No. 3724 under the Interna- tional Visitor Leadership Program between the National Academy of Sciences and the Academy for Educational Development. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13:  978-0-309-11613-8 International Standard Book Number-10:  0-309-11613-9 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM and NRC (Institute of Medicine and National Research Council). 2008. Foodborne disease and public health: Summary of an Iranian–American workshop. Washington, DC: The National Academies Press. 

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern- ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the char- ter of the National Academy of Sciences, as a parallel organization of outstand- ing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 



Planning Committee on FOODBORNE DISEASES AND PUBLIC HEALTH: AN IRANIAN–AMERICAN WORKSHOP MICHAEL P. DOYLE (Chair), Center for Food Safety, University of Georgia, Griffin WILLIAM E. KEENE, Acute and Communicable Disease Division, Oregon Department of Human Services, Portland KARL R. MATTHEWS, Department of Food Science, Cook College, Rutgers, The State University of New Jersey, New Brunswick J. GLENN MORRIS, JR., Emerging Pathogens Institute, University of Florida, Gainesville Consultant Writer CAROL WEST SUITOR, Nutrition Consultant, Northfield, Vermont Staff MARIA ORIA, Senior Program Officer SANDRA AMAMOO-KAKRA, Program Associate GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board GLENN SCHWEITZER, Director, Office for Central Europe and Eurasia, Policy and Global Affairs Division  



Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and respon- siveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Craig Hedberg, University of Minnesota School of Public Health, Minneapolis George J. Jackson, Food and Drug Administration Alumnus, Washington, DC Karl Matthews, Rutgers, The State University of New Jersey, New Brunswick Ewen Todd, Michigan State University, East Lansing Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was over- seen by Arthur Reingold of University of California, Berkeley. Appointed vii 

viii REVIEWERS by the Institute of Medicine, he was responsible for making certain that an independent examination of this summary was carried out in accor- dance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this summary rests entirely with the authors and the institution. 

Preface and Acknowledgments I n November 2007 the Food and Nutrition Board (FNB) of the Institute of Medicine (IOM) hosted a U.S.–Iranian workshop in Washington, D.C., on the subject of foodborne diseases and food safety. The two- and-one-half day workshop was an important component of a three-week program for Iranian visitors to the United States that was sponsored by the Department of State and carried out with the assistance of the Acad- emy for Educational Development (AED). The program was designed to acquaint 20 Iranian specialists from five universities and research cen- ters with U.S. approaches to the control of foodborne diseases. At the same time, the workshop and other aspects of the program offered the opportunity for a number of U.S. specialists to become acquainted with Iranian approaches to addressing foodborne diseases. The agenda for the workshop is provided in Appendix A; the participants in the workshop are identified in Appendix B. The workshop was a continuation of U.S.–Iranian cooperative efforts in the field of foodborne diseases that began in 2003. These efforts included three events prior to the 2007 workshop. In June 2003, specialists selected by the IOM and the Iranian Academy of Medical Sciences held a planning session in Les Treilles, France, for joint activities. In October 2004 the first of these joint activities took place: a U.S.–Iranian workshop hosted by the Research Center for Gastroenterology and Liver Diseases of Shaheed Beheshti Medical University in Tehran. The proceedings were published ix 

 PREFACE and acknowledgments in 2006. Against this background in cooperation, the Research Center for Gastroenterology and Liver Diseases carried out a jointly designed pilot project during 2006 and 2007 to demonstrate improved approaches to foodborne disease surveillance in a region with a population of 130,000 people centered about 70 miles to the northeast of Tehran. The pilot proj- ect is described in this report. FNB selected the U.S. participants in this workshop. The Research Center for Gastroenterology and Liver Diseases selected the Iranian par- ticipants. Representatives from those two organizations jointly developed the agenda for the workshop. See page v for members of the planning committee. This summary of the workshop proceedings presents the principal issues raised during the presentations and discussions at the workshop. The summary highlights many common interests that Americans and Iranians share in various aspects of controlling foodborne diseases. The summary also addresses topics related to microbiology and cancer that may be of interest for future U.S.–Iranian collaborative efforts. Following the workshop, the Iranian visitors had the opportunity to continue discussions with a number of U.S. counterparts at their home institutions in the United States and to visit several research, surveillance, and related facilities in the states of Washington, Oregon, and Georgia and in the Washington, D.C., metropolitan area. These facilities are identified in Appendix C. The visits to these institutions were arranged by AED in cooperation with the Department of State and FNB. As background to provide readers with useful context for some of the content in Chapter 7, “Opportunities for Future Collaboration” a brief description of the current relationship between Iran and the U.S. Histori- cally, the Iranian scientific community has had strong attachments to the U.S. scientific community, but political relations between the two countries have been constrained for some time. In the wake of the attacks on the World Trade Center on September 11, 2001, scientific interactions between the United States and Iran became even more challenging. Obtaining U.S. visas, for example, has been a major obstacle. The Department of State, as well as the Iranian government and many members of the scientific communities in the two countries, has taken the position that science-related engagement can contribute to solutions of global problems and also help improve understanding of each country’s society and politics. During the past eight years, the U.S. National Acade- mies have sponsored annual U.S.–Iran scientific workshops in both coun-   National Research Council. 2006. Food safety and foodborne disease surveillance systems: Pro- ceedings of an American-Iranian Workshop. Washington, DC: The National Academies Press.   Neureiter, N., and G. Schweitzer. 2008. Engaging Iran. Science 319(Jan 18):258. 

PREFACE and acknowledgments xi tries. These workshops and related individual exchanges have shown that cooperation on problems of mutual interest is possible even in harsh political environments. These mutual efforts can build bridges between the two countries. Special appreciation is extended to the Department of State, which provided financial support for the workshop, and to AED, which arranged the logistics for the visitors to travel from Iran to the United States and within the United States. The members of the IOM planning committee deserve recognition for their role in developing the agenda, identifying U.S. participants, and planning national visits for the Iranian visitors. The tireless efforts of Mohammad Reza Zali, the director of the Research Center for Gastroen- terology and Liver Diseases, to organize the group of Iranian participants and to make the necessary arrangements in Tehran for their visit are greatly appreciated. His contributions to developing the agenda and to making this visit a success were invaluable. Of special importance were the suggestions made by Maria Oria and Linda Meyers, who provided the staff leadership within FNB in organizing the workshop and in preparing this report. Special thanks for her efforts in preparing this summary go to Carol West Suitor. Lastly, the Iranian and U.S. participants of this workshop deserve full appreciation. This workshop would not have happened without their commitment to science, collaboration, and the improvement of public health. Glenn E. Schweitzer Director, Office for Central Europe and Eurasia Policy and Global Affairs Division National Research Council 



Contents OVERVIEW 1 1 INTRODUCTION 3 Specific Objectives, 3 Background, 4 2 FOODBORNE DISEASE SURVEILLANCE IN IRAN AND IN THE UNITED STATES 9 Iranian Foodborne Disease Surveillance System Pilot Project, 9 Foodborne Disease Surveillance in the United States, 15 PulseNet USA: The National Molecular Subtyping Network for Foodborne Disease Surveillance, 19 Discussion, 23 3 SELECTED GASTROINTESTINAL DISEASES IN IRAN AND THEIR INVESTIGATION 27 Current Technical and Scientific Aspects of Foodborne Disease in Iran, 27 The Research Department of Foodborne and Diarrheal Diseases, 29 Rotavirus, 31 Prevalence and Genetic Diversity of Entamoeba histolytica and Entamoeba dispar in Iran, 31 Distribution of Salmonella Subspecies in Iran, 32 xiii 

xiv CONTENTS Helicobacter Pylori in Iran, 33 The Burden of Gastrointestinal Disease in Iran, 34 Discussion, 36 4 APPLYING RISK ASSESSMENT METHODS TO FOOD MICROBIOLOGY 37 Risk Assessment Methods, 37 Evaluation of Risk–Risk Trade-Offs, 42 Discussion, 45 5 POTENTIAL ASSOCIATIONS BETWEEN FOODBORNE AND CHRONIC DISEASES 46 Signaling Pathways Involved in Cancer, 46 Molecular and Genetic Aspects of Colorectal Cancer, 48 Screening of High-Risk Populations for Colorectal Cancer in Iran, 50 Diet, Microbiota, and Carcinogenesis, 53 Human Microbiome Project, 56 Discussion, 58 6 APPROACHES TO HEALTH EDUCATION 61 Integrated Medical Research Training at the University of California, 61 Health Education in Iran, 64 Supercourse—The Global Health Network, 68 Discussion, 69 7 OPPORTUNITIES FOR FUTURE COLLABORATION 72 Joint Workshop Topics, 72 Other Forms of Collaboration, 73 Closing Remarks, 75 REFERENCES 76 APPENDIXES A Workshop Agenda 79 B Workshop Participants 83 C Site Visits 91 D Abbreviations 93