Food system drivers of global foodborne bacterial disease burden: Pathogen-specific attribution using 1990-2021 GBD 2021 and FAO food system databases, with implications for food safety control.

Foodborne bacterial pathogens cause significant global illness and death, but data on their food transmission and links to food systems are limited. This study integrates the Global Burden of Disease (GBD) 2021, WHO-derived food-attribution fractions (FAFs), and the FAO food system across 204 countries (1990-2021). It quantifies the foodborne-attributable burden of bacterial pathogens (EPEC, ETEC, non-typhoidal Salmonella, Shigella, Campylobacter, and L. monocytogenes) and examines associations within the food system through network pathway analysis. These pathogens caused an estimated 364,500 deaths from diarrheal diseases (age-standardized death rate, ASDR 3.63/100,000) and 11,100 from meningitis (ASDR 0.12/100,000), with corresponding DALYs of 24.61 million (age-standardized DALY rate, ASDALY 312.95/100,000) and 699,500 (ASDALY 8.90/100,000) in 2021. The Burden was concentrated in Sub-Saharan Africa and South Asia (78.7% of global DALYs), with low-SDI regions experiencing 195-fold higher diarrheal diseases ASDALY than high-SDI settings. Age-standardized rates declined substantially (estimated annual percentage change, EAPC of diarrheal diseases: -4.35%), yet high-SDI countries exhibited stagnation in diarrheal diseases mortality (ASDR EAPC: +0.63%). Network pathway analysis revealed that socioeconomic development (SDI: ρ = -0.830) mediated unexpected production-burden relationships. Animal-source food production negatively correlated with pathogen burden (ρ = -0.28 to -0.22), indicating food safety capacity, while plant-associated pathogens positively correlated with vegetable and legume production (ρ = +0.20 to +0.41) in low-SDI settings. Projections indicate declines in meningitis (64.59%) and diarrheal diseases (69.50%) by 2050, with Sub-Saharan Africa facing a burden 51.66 times higher for diarrheal diseases and 29.73 times higher for meningitis than high-income regions. These findings indicate food safety infrastructure, not production volume, influences foodborne disease outcomes, supporting targeted interventions based on pathogen-food combinations and regional contexts.