Agenda Item 8.3 Codex Alimentarius Commission November 2021
Dr Francesco Branca
Director Nutrition and Food Safety
World Health Organization
Avenue Appia 20
1211 Geneva 27
Switzerland 27th September 2021
Dear Dr. Branca,
Following on from our warm appreciation of WHO’s celebration of the 40th Anniversary of the Code, on behalf of the International Baby Food Action Network (IBFAN) we are writing to you now regarding the 2021 draft Global Strategy for Food Safety, in the hopes that the final publication can be strengthened.
In 2002, IBFAN welcomed the adoption of the Global Strategy for Infant and Young Child Feeding and have appreciated WHO’s continuing efforts to assist governments of member states to implement it with the aim of fostering the healthy growth and development of infants and young children. In the same way IBFAN now welcomes the 2021 draft Global Strategy for Food Safety and made a submission to the July 2021 online questionnaire in order to underscore the importance of food safety for the most vulnerable populations of all.
Before addressing our specific concerns about this we would like to welcome the highlighting in the draft strategy of conflicts of interest safeguards and the need for food safety systems to protected from undue commercial influence. While acknowledging the challenges for national governments we consider these issues to be of fundamental importance if food safety strategies and coalitions are to maintain and deserve public is trust. We make one request in this regard: to remove the business term ‘stakeholder’ and instead use terms that more accurately describe the many different sectors, constituents, participants that have an interest in public health policies or strategies. As an NGO with a strict COI funding policy that stays closely to its public health remit with no business agenda, we feel excluded from the many new ‘multi-stakeholder collaborations!
In relation to infant and young child feeding, we are realized that the points we made in the online section of the ‘introduction’ do not appear to have been recognized by the system. We reiterate them overleaf in the hopes that they can be considered again for the introductory section, not least to ensure safer feeding of powdered baby milks and cereals and lessen the risk of infants and young children ingesting a double dose of toxins.
We are pleased that the Introduction recognizes that compromised immune systems lead to increased health vulnerability and that unsafe food and water disproportionately affect vulnerable groups in society, particularly infants and young children. However, the draft strategy fails to mention the importance of breastfeeding and touches only minimally on the risks of artificial feeding
As you know, IBFAN has worked since its founding in 1979 to ensure the safety of infant and young child feeding for the youngest members of our society. Newborns, infants and young children are the populations most vulnerable to food safety hazards. The 2001 WHO Global Strategy for Infant and Young Child Feeding thus recommends the early initiation of breastfeeding, followed by exclusive breastfeeding for six months and continued for two years or beyond with the addition of safe and nutritious complementary foods after six months.
Optimal infant and young child feeding practices provide anti-infective agents and immune factors to protect infants and young children against bacterial, parasitic, and viral infections and to boost the maturation of the immune system. For infants and young children who are not breastfed, the contamination of commercial baby milks and foods has the most serious impact on their health and development. This is because these products are the sole source of sustenance during the first years of their life.
Commercially manufactured formulas for infants and toddlers, as well as cereal-based complementary foods, are ultra-processed products which contain no live cells and provide no such protection against disease or boost to the immune system. Instead, they may become contaminated during the production process by pathogenic bacteria such as Salmonella species, Cronobacter/Enterobacter sakazakii or Bacillus cereus, as well as many more. Bacillus cereus is a spore-forming bacterium found in dried food products for infants and young children and is prevalent in China, Iran and many other countries (see below.)
Risks from unsafe water:
Breastfeeding is lifesaving in emergencies and babies are at greatest risk of water-related diseases, with diarrhoeal disease the second biggest killer of under-fives. Breastfeeding is resilient and provides food, care and immune support, and protection from the worst of emergency conditions.
Clean, safe or potable drinking water, containing no chemical contaminants or pathogens, is essential to prepare powdered milk – including soy-based formulas and cereal-based foods and drinks for infants and young children in powder form. If water is contaminated by toxic chemicals such as arsenic and cadmium or by pathogenic bacteria, infants and young children may ingest a double burden of chemical and microbial contaminants. This is when they are at their most vulnerable and when antimicrobial resistance is increasing worldwide, making it harder to treat infections. Arsenic in soil and water is a serious problem in developed countries such as the USA, and in developing ones like Bangladesh. Cereals and rice grown in arsenic-laden water are used to manufacture cereal- based and rice-based baby foods. Rice-based baby foods are not only high in inorganic arsenic, the most toxic form of arsenic, but may also be contaminated with four toxic metals, including lead and mercury as well as cadmium. Cadmium is a toxic trace element that is used as an agricultural fertilizer and is found in microplastics that contaminate farm soil. https://www.ehn.org/plastic-in-farm-soil-and-food-2647384684/particle-8 Even the supposedly organic brown rice syrup added as a sweetener to formulas and foods may be contaminated by arsenic present in soil and water in many regions where rice is cultivated. Even in Switzerland, where municipal tap water was considered safe to drink, water in many Alpine regions exceeds WHO standards for TDI in drinking water. This means that infants and young children fed powdered milk and cereal commercial products may be at serious risk of cumulative exposures.
In many countries and settings, the main problem remains bacterial contamination of water sources causing many waterborne illnesses. The scarcity of safe water means that water used to prepare bottles for infant feeding and as drinking water for young children can be contaminated and can transmit diseases such diarrhoea, still in this century the leading cause of child deaths in many African, LAC and Asian countries, as well as cholera, dysentery, typhoid, and polio. Contaminated drinking water is estimated to cause 485 000 diarrhoeal deaths each year. By 2025, half of the world’s population will be living in water-stressed areas.
Intrinsic microbiological contamination: We appreciate WHO’s work on the problem of intrinsic contamination of powdered foods for infants and young children. After reports increased in 2000 alerting health care professionals to mortality and morbidity caused by species of Salmonella and Enterobacter/Cronobacter, the WHA adopted two resolutions in 2005 and 2008 (WHA 58.32 and 61.20). These called on WHO to prepare guidance on safe preparation, storage and handling of powdered infant formula and WHO and FAO accordingly organized three Joint Expert meetings with FAO to discuss and produce the 2007 FAO/WHO Guidelines on safe preparation, storage and handling of powdered infant formula (PIF.) These resources should be named and listed in this document, with accessible weblinks, Enterobacter sakazakii and other microorganisms in powdered infant formula: meeting report: Microbiological Risk Assessment series 6.
- Enterobacter sakazakii and Salmonella in powdered infant formula: meeting report: Microbiological Risk Assessment series 10 https://www.who.int/publications/i/item/9241563311
- Enterobacter sakazakii (Cronobacter spp.) in powdered follow-up formula: meeting report: Microbiological Risk Assessment series 15 https://www.who.int/publications/i/item/9789241563796
- Safe preparation, storage, and handling of powdered infant formula: guidelines https://www.who.int/publications/i/item/9789241595414
- The information for parents and caregivers on preparation of infant formula is of critical importance for emergency and relief workers and thus can also be found here: https://www.ennonline.net/infantformulaguidelines.
- Infosan in action to control an outbreak of Salmonellosis linked to infant formula: https://www.who.int/news/item/23-02-2018-infosan-in-action-to-control-an-outbreak-of-salmonellosis-linked-to-infant-formula.
Article 9.2 of the International Code addresses labelling and calls upon manufacturers and distributors to include instructions on labels for appropriate preparation and a warning against the hazards of inappropriate preparation.
We would also like to point out that these 2007 FAO/WHO Guidelines use the word ‘safe’ when in fact feeding powdered formula can never be entirely safe. The risk can only be reduced and not eliminated. Furthermore, it is not only powdered infant formula but also follow-up and toddler formulas that can become intrinsically contaminated with harmful bacteria such as Bacillus cereus found in dried food and milk products. The 2008 report of the 3rd Joint Expert meeting addressed these powdered follow-up formulas in the EFSA Opinion on Bacillus cereus and other Bacillus spp in foodstuffs: https://efsa.onlinelibrary.wiley.com
In the light of our many concerns, we urge the Departments of Nutrition and of Food Safety to ensure that our comments are addressed in the Strategy and also that the 2007 Guidelines are updated and revised. This would help ensure that WHO’s technical assistance and guidance to national Nutrition and of Food Safety Departments is in line with WHA resolutions 58.32 and 61.20, whilst also ensuring full implementation and monitoring of national compliance with the International Code of Marketing of Breastmilk Substitutes and its subsequent relevant resolutions.
We thank you and look forward to continued close collaboration in the protection of child health.
IBFAN Global Council
Dr J P Dadhich and Nomajoni Ntombela (Co-Chairs) Dr Marina Rea, Barbara Nalubunga, Dr Marcos Arana and Patti Rundall
Convenor, IBFAN global working group on chemical and microbiological contamination of infant feeding products
Maryse Arendt, IBCLC, member of the IBFAN global working group on chemical and microbiological contamination of infant feeding products
Elisabeth Sterken, Chair of IBFAN Codex Working Group.