SOCIAL AND ECONOMIC IMPACTS AND MANAGEMENT OF SHRIMP DISEASE
AMONG SMALL-SCALE FARMERS IN THAILAND AND VIETNAM

Pornlerd Chanratchakool¹ and Michael J. Phillips²

¹Aquatic Animal Health Research Institute
Department of Fisheries
Kasetsart University Campus
Jatujak, Bangkok 10900, Thailand

²Network of Aquaculture Centres in Asia-Pacific
PO Box 1040,Kasetsart Post Office
Bangkok 10903, Thailand

Chanratchakool, P., and M.J. Phillips. 2002. Social and economic impacts and management of shrimp disease among small-scale farmers in Thailand and Vietnam. p. 177-189. In: J.R. Arthur, M.J. Phillips, R.P. Subasinghe, M.B. Reantaso and I.H. MacRae. (eds.) Primary Aquatic Animal Health Care in Rural, Small-scale, Aquaculture Development. FAO Fish. Tech. Pap. No. 406.

ABSTRACT

Shrimp farming in Thailand is dominated by small-scale farms, which make up around 80% of the total number. Whilst shrimp aquaculture has contributed to income generation among coastal communities, disease outbreaks have caused significant economic losses to farmers and the country in recent years. Outbreaks of white spot syndrome virus (WSSV) and yellowhead virus (YHV), as well as bacterial diseases which struck later in 1997, led to the overall shrimp production of Thailand being reduced by 30% (from 210,000 to 150,000 mt). These diseases had a serious impact on all farmers, especially small-scale farmers whose main income was derived from shrimp farming. Moreover, at least 60% of small-scale farmers are thought to have become indebted to banks due to production lost as a result of shrimp disease. This paper discusses some of the impacts of disease outbreaks on small-scale farmers and reviews the strategies adopted by farmers to manage risks associated with shrimp disease.

The shrimp farming situation in Vietnam is very different from that in Thailand, as shrimp farming is mainly low input and extensive. Shrimp farming also provides an important source of income in some coastal areas and has potential to contribute to poverty alleviation among coastal communities. A project supported by the Australian Centre for International Agricultural Research (ACIAR) looked at the impacts and management of shrimp disease problems among extensive farms in Ca Mau Province of the Mekong Delta, as part of a project for improving the social and economic returns to farmers from "mixed shrimp-mangrove" farming systems. The households in the project area were primarily dependent on aquaculture and capture fishery as the main source of family income, the majority being dependent primarily on shrimp aquaculture. The average household income in 1996 was 12.08 million Dong/household/yr, equivalent to around US$1,000 at 1998 exchange rates), or 2.4 million Dong/person/yr (US$170/caput/yr). Poverty thresholds as quoted by the United Nations Development Programme (UNDP) in 1995 were around 1.1 million Dong/person/yr. An estimated 40% of households were below this threshold, showing a significant poverty problem in the area. Shrimp culture provides an opportunity to improve incomes and contributes to poverty alleviation, although effective management to reduce risks associated with disease outbreaks is required. Disease outbreaks severely affected shrimp yields in the Mekong Delta area from 1996, leading to negative social and economic impacts on farm households, including reduced incomes and increased debt. In 1997, mass mortalities occurred four times (in January, June, July and October), and were associated with high prevalence of WSSV and adverse environmental conditions associated with poor water and soil quality. The disease problem was also compounded by the low educational level of most farmers, farmer inexperience with aquaculture, and lack of access to technical advice and to capital to invest in farm improvements and risk-reduction measures. The implementation of technical recommendations for reducing disease risk is closely interlinked with educational, institutional, social and economic conditions. In particular, better educational opportunities, more flexible and accessible credit arrangements, and greater access to regular technical support are key factors in determining the willingness and capacity of farmers to implement farm-level risk management strategies. In view of the lack of technical support in the area, much closer co-operation among farmers, building on existing farm groups, is also important to promote effective self-help and extension of support.

BACKGROUND

This paper gives information on the social and economic impacts of disease on small-scale shrimp farms in two contrasting environments; the first in Thailand, which is the world's major shrimp-producing country; and the second in Vietnam, where shrimp farming is mainly low input and extensive. The case in Vietnam is particularly relevant to the topic of this consultation, as it deals with the social and economic impacts of disease on a poverty-focussed project in the Mekong Delta and the development of management strategies which are appropriate to the farmers' social circumstances and farming system.

SOCIAL AND ECONOMIC IMPACTS OF SHRIMP DISEASE IN THAILAND

Thailand, as the world largest shrimp producer since 1992, has faced many disease problems, as well as other management-related problems. Shrimp diseases are most serious, since they can cause losses from low (chronic) levels up to acute (100%) mortalities. The production of Thai shrimp, which was increasing every year, reached its highest level in 1994, when 250,000 mt were produced. Due to disease and management problems, production started to decline, first to 225,000 mt in 1995 and then to 205,000 mt in 1996. The major pathogens affecting the Thai shrimp industry are white spot syndrome virus (WSSV), yellowhead virus (YHV) and bacterial diseases (vibriosis). In 1997, another 30% decline in production occurred, only 150,000 mt of shrimp being produced in that year.

WSSV is the major cause of mortality in Thai shrimp farming. Many attempts have been made to understand this problem and many recommendations aimed at preventing disease outbreaks have been made. This concerted effort by farmers and supporting institutions has resulted in an increased production to 230,000 mt in 1998. Farm management strategies have been developed depending largely on farming conditions, as indicated below.

Economic Impacts of Disease

White spot disease, caused by WSSV, has now been reported from most Asian countries. It has also been reported as "red body," systemic ectodermal and mesodermal baculovirus (SEMBV) and PJ-RV. The infection will be referred to here as "white spot disease," since the presence of white spots on the carapace is the most noticeable of the clinical features.

When outbreaks first appeared, they were all associated with extremely severe production and economic losses, and the virus appeared to be highly pathogenic. If shrimp were exposed to enough of the virus, they would die, regardless of the environmental conditions. Losses due to WSSV alone were estimated at US$600 million in Thailand in 1997, and at over US$2 billion throughout Asia in the same year (Flegel 1998). Now, however, infections appear to cause severe losses only if the shrimp are also suffering from poor environmental conditions in the ponds. It is still not clear if this change has been due to an alteration in the virus, the host or to other factors, including the implementation of better management practices by the farmers. The direct economic impact of the virus appears to have decreased.

Other estimates of economic losses due to shrimp disease in Thailand include an estimated US$30.6 million from yellowhead disease in 1992 (Nash et al. 1995), and US$650 million from all shrimp disease outbreaks in 1994 (Flegel et al. 1995). Flegel (1998) pointed out that YHV and WSSV are currently the most serious diseases threatening the shrimp farming industry in Thailand. Together, these two pathogens may be responsible for the drop in shrimp production in Thailand from 250,000 mt in 1994 to 220,000 mt in 1995. At approximately US$8/kg, this represented a shortfall of $240 million. However, this small difference in production is not a true reflection of the full impact of these diseases. At that time, Thai production was rising at approximately 20,000 to 30,000 mt per year, and production for 1996 had been expected to rise correspondingly. The diseases were thus estimated to have caused the loss of 70,000 mt of shrimp (around 40% of total production) in 1996 (Alday-Sanz and Flegel 1997). At a rough estimate of $US3-5 per kg profit, this represents between $US210 and $US350 million in lost revenues. Also, these figures do not include losses in related businesses such as feed production, processing plants and feed raw material producers, and the income lost by labourers.

Socio-economics and Impacts on Small-scale Farmers

The socio-economics of small-scale farmers have been studied, although the impacts of disease at the household level in Thailand are surprisingly less well understood. Some information on the cost-profit of Thai shrimp farming along the Gulf of Thailand was determined from a survey of 104 farms in Nakhon Sri Thammarat and Songkhla provinces (Nipanpong and Sidthimunk 1998). The survey split the farms into six groups depending on their area. The first three groups were small farms (less than 1.6 ha) and represented almost 90% of the total number of farms surveyed. There are a number of important features that have implications for disease control and management of shrimp aquaculture:

• These farms were arranged into three groups: (1) farms smaller than 0.5 ha (32%), (2) farms between 0.5-0.8 ha (35%) and (3) farms between 0.8-1.6 ha (33%).

• The cost-profit analysis for each group revealed that the least profit (0.6 US$/kg) (38.5 Baht = 1 US$) was obtained by the smallest farms (equivalent to US$725/farm/crop at this time).

• Sixty percent of the farmers in the group with the smallest-sized farms had one to five years experience, whereas over 50% of the farmers from the group with the largest-sized farms had more than five years experience. This indicates that farmers with smaller farms were just moving into this business and had limited experience with shrimp culture.

• More than 50% of the total number of farmers sampled learned from, and followed the technology used by, their neighbours. Most farm owners were between 41-50 years old and had a low level of education.

• The major source of income for 65% of the farmers came from shrimp culture.

• The average mortality of shrimp reported in this survey was between 46-54%, and was mainly due to disease and management problems.

• During the survey period, farmers still achieved profits, since serious outbreaks of disease started in 1996 and 1997.

The reduction of total production by 30% that occurred in 1997 was estimated to have a value equivalent to US$600 million, a figure which excludes losses in related businesses such as feed production, processing plants, and feed raw material production, and in labour. When the same losses were applied to the smallest farm group, a 30% production loss was equivalent to a loss of around US$1,000/pond/crop. As 65% of the farmers were reliant on shrimp as their main source of income, it is not surprising that disease was reported to have serious impacts on households involved in shrimp culture. This aspect needs to be better understood, and some further information is given in the paper by Adis Israngkura contained in this volume.

Management of White Spot Disease

One of the many problems associated with the management of viral diseases is that there is increasing evidence that clinical signs similar to those seen in white spot disease may occur in shrimp that are not infected with WSSV. It would appear that if the virus is present in a population, a rapid rise in mortalities is associated with environmental deterioration. Most dead shrimp will either have no clinical signs or will have the clinical signs typically associated with the viral infection i.e., white spots. If the environment does not deteriorate, it is unlikely that mass mortalities will occur. In some cases, chronic low-level mortalities are seen with the shrimp showing signs of external fouling, vibriosis or other conditions. Some of these animals may also show white spots, but if the mortalities are low, the virus may not be present. These findings emphasise the difficulty of correctly diagnosing viral diseases based solely on gross clinical signs, and the importance of environmental management as a means of controlling economic losses due to disease.

Although a great deal of information is still lacking regarding these very serious viral conditions, some general recommendations for their control have been developed. Prevention has to be based on not only maintaining a healthy environment, but also on keeping the virus out of the system. For white spot disease, the most common route of infection is through entrance with infected postlarvae (PL). However, in some cases the virus enters the population with the incoming water or via wild crustaceans. Outbreaks due to WSSV can be prevented by eliminating potential vectors and screening intake water. However, serious outbreaks can still occur in ponds stocked with infected PL. Using the polymerase chain reaction (PCR) to screen for infected PL is one way to reduce this risk (Flegel et al. 1997, Kasornchandra et al. 1997). The technique is now used in many countries with varying results. PCR is very sensitive and can, therefore, detect small numbers of the virus in individual animals. However, the technique is not as effective where populations are large and only a small number of individuals are infected. This might explain why outbreaks still occur in ponds with PL certified as PCR-negative.

Since outbreaks of white spot disease often stem from infected PL, elimination of such animals from the population before stocking can reduce the likelihood of disease. Formalin, at a concentration of 150 ppm, can be used to treat PL for 30 minutes. After treatment, weak and unhealthy individuals should be separated from actively swimming shrimp and discarded. This technique successfully reduces the number of infected PL stocked into ponds (Limsuwan 1997). However, if the prevalence of infection is high, this technique may not be practical, especially when climatic conditions fluctuate.

It is important to keep predators and competitors out of the pond. Initially, the pond should be filled and the water treated with calcium hypochlorite at 15 to 20 ppm active chlorine. After the pond is filled, water exchange should be reduced to a minimum for at least the first month after stocking. Water should only be exchanged when it is necessary, not as a routine procedure. It is also important to ensure that the incoming water is free from animals and has not been contaminated by wastes from other farms. A reservoir is essential for treatment of incoming water.

The main aim of low water exchange is to minimise contact with poor quality or contaminated water from outside the farm. Partial recirculation is the system of low water exchange most commonly used in Asia. When water cannot be pumped into the farm, effluent from the production ponds is first allowed to settle and may be treated before being mixed with the water reserve. The reserve water is pumped from the external water supply when conditions are suitable, or from an inlet reservoir. In most partial recirculation systems, harvest effluents are not introduced to the mixing reservoir, but are normally passed through a settlement system before discharge (Chanratchakool et al. 1998).

Although, infections can spread between ponds on a single farm, when more than one pond is affected with white spot disease it is usually due to a common source of infected PL. None-the-less, unless it is absolutely unavoidable, equipment should not be used in more than one pond. If equipment is to be moved between ponds, it must be first thoroughly cleaned and disinfected.

If an infection does get into the population and an emergency harvest is not appropriate, it has been suggested that removing the affected shrimp may limit the spread of the infection within the pond. The affected shrimp will usually be seen at the surface of the pond, especially in the morning and evening.

Moving shrimp between countries, or between distinct areas within a country, should be avoided, wherever possible. Moving stocks of shrimp not only carries the risk of introducing disease to farms, but may also have adverse effects on local populations of wild shrimp.

If a new infection occurs, it is important that it not be allowed to spread to neighbouring farms. Dead shrimp should be removed from the pond and disposed of in a manner that does not contaminate the water supply. They can either be buried with quick lime, or they can be burned. The water from the affected pond should not be discharged from the farm. Once the infection is detected in the shrimp, it may be possible to conduct an emergency harvest. The water from an emergency harvest should be retained in a settling pond and treated with calcium hypochlorite (at least 20 ppm active chlorine). In some cases, it may not be worth conducting an emergency harvest, for example, if the shrimp are too small or if most have already died. In such cases, the water should be treated in the pond prior to discharge. Every effort should be made to avoid the water from the affected pond coming into contact with the inlet water of the affected farm or of any neighbouring farms.

Early detection of the problem is extremely important. The shrimp should be examined regularly for signs of disease, especially if there is an increased risk of infection.

Management Recommendations for Small-scale Farms

Small, newly developed shrimp farms are owned by rice or fish farmers who follow management techniques learned from neighbouring farmers. Their farms consist of one to three ponds, and more than 80% of them take their water directly from the source, without using a storage reservoir. Poor-quality water supply is one of the major problems leading to management difficulties and diseases causing severe losses. Some farmers have returned to rice or fish farming. However, as the income generated from rice or fish is relatively low and is inconsistent, large families still need to generate incomes from other agriculture-based activities. Integrated farming has shown a good potential for farmers living in coastal areas. Dividing the land into three or four parts consisting of a shrimp pond, a fish pond (which serves as a source of water for the shrimp pond), a rice paddy or a cash crop (such as vegetables), and an area for raising poultry is recommended. One or two shrimp-production cycles per year generate the major income for the family, whereas fish, rice, poultry and cash-crop production provide extra income and food for direct consumption.

Institutional Analysis

Since income generation from shrimp production has become a focus for poverty alleviation for poor farmers in coastal areas, information and technology transfer are required in order to ensure success. Extension material and technical support in various forms are being developed and transferred though both the government and private sectors.

Disease control and management in Thailand is not the responsibility of a single governmental body. Many institutes have been involved in the successful development of the shrimp-farming industry during the past 12 years. Governmental agencies, such as the Department of Fisheries, the universities, various research institutes and the private sector have jointly set up a good network to study the causes, preventive methods and treatments for diseases, as well the development of good management practices for shrimp farming. This information and recommendations are being transferred to the end-users by various means, such as seminars, workshops and training courses that are jointly organised by the government and private sectors, and via scientific publications and articles produced by various institutions and widely circulated among the interested parties. There are also government and private laboratories that provide services for disease diagnosis in difference areas, which all farmers can easily access.

When management recommendation are made, they can easily reach the end-users through the many institutions set up in Thailand. However, their successful application depends largely on the farmer's decision. In order to assist the farmers, more well-trained and experienced local staff are still greatly needed, since the shrimp culturing area in Thailand is quite large. Establishing a disease reporting system is one effective strategy to obtain information from the field, and can be used to pass recommendations back to the farmer quite effectively.

SHRIMP DISEASE AND A POVERTY-FOCUSSED SHRIMP AQUACULTURE DEVELOPMENT PROJECT IN THE MEKONG DELTA, VIETNAM

The Mekong Delta is Vietnam's most important shrimp-producing area, with nearly 200,000 ha of ponds. In the southern tip of the delta, the Government of Vietnam is undertaking a mangrove reforestation programme, and mixed brackishwater farming systems - mangrove and aquaculture - are practised. The propose of the mixed farming system is to provide wood through mangrove reforestation and food and income to people involved in mangrove planting through brackishwater aquaculture. Until recently, this brackishwater aquaculture was solely shrimp aquaculture, but the systems have recently become more diversified. The people living in the area are poor, and an estimated 40% are living below the "official" government and United Nations Development Programme (UNDP) poverty thresholds. The reforestation and aquaculture-development activities in the southern part of the delta, therefore, have a strong poverty alleviation focus.

As part of a project to improve the economic returns and management of these mixed-farming systems, the Australian Centre for Agricultural Research (ACIAR) has supported a research project in Ca Mau Province. Two enterprises, Tam Giang III and SFFE 184, in the Ngoc Hien District of what is now Ca Mau Province were selected as the main foci for research activities, in consultation with national, provincial and enterprise officials. The enterprises are designated by provincial authorities as State Fisheries-Forestry Enterprises (SFFEs).

Description of the Mixed Farming Systems

Two main fisheries-forestry farming systems presently operate in Ngoc Hien District are:

• Traditional capture fisheries-mangrove forestry farming system. In this system, being carried out in Kien Vang Enterprise, mangrove forest occupies more than 80% of the enterprise area. Here, forest management aims to produce a final yield of 200 m3 wood/ha when harvested at year 20. Fisheries products come from capture fisheries only; pond culture is not practised.

• Fisheries-forestry farming system. In this system, practised in the Tam Giang III and SFFE 184 Enterprises, farm households are officially assigned 5-10 ha of land on which they must carry out both shrimp culture and forestry. Two different farming models are practised in Tam Giang III, (i) separate pond (20-30% of farm) and forest (70-80% of farm) areas; and (ii) combined shrimp farming-mangrove forestry on the same area of land. Shrimp culture is carried out in canals or channels dug in the forest. The area for shrimp farming (canals, channels and levees) is restricted to 20-30% of the total farm area. Both the separate and combined models are used in Tam Giang III, but most farms in SFFE 184 use the combined model.

Description of Farm Households

Household surveys carried out in 1996 revealed information on household incomes, and demonstrated the overwhelming importance of aquaculture and aquatic products to people living in the enterprises. The average reported household income was 12.08 million Dong/household/yr (equivalent to around US$870 at 1999 exchange rates), or 2.4 million Dong/person/yr (US$172/yr). Poverty thresholds are around 1.1 million Dong/person/yr. It was estimated that 80 (39.4%) of the surveyed households were below this threshold, indicating a significant poverty problem in the enterprises.

Traditional farmers or those making limited investment in their ponds reported lower incomes than did extensive farmers, although the survey suggested that farm households that had made investment had significantly more debt, as a result of borrowing funds to purchase seed and undertaking some pond improvements. Table 1 shows the relative contribution of the different activities to family income (data from both enterprises are combined).

Table 1. Sources of household income in two forestry-fishery enterprises (n=194).

The survey noted differences in income patterns between the different farming systems. Farmers reported that they can obtain higher production from models with stocking, but will suffer a greater loss if they lose the crop. In other words, households can generate greater income by undertaking shrimp stocking and pond improvements, but they are also exposed to a higher risk of crop losses because of shrimp disease outbreaks.

Aquaculture Problems and Constraints

Farmers reported several aquaculture problems, which were explored by questionnaire and during the local participatory workshops. Information on the technical and nontechnical problems faced by farmers is shown in Table 2.

Environmentally related problems, including water and soil-related problems, were faced by a significant proportion of farmers. These included problems that were perceived as being due to water pollution, turbidity and water acidity. The water quality problems were similar between farm types. The major problems included shallow ponds, acidic soils, and poor productivity caused by high turbidity. Other aquaculture-related problems reported by farmers included lack of credit, lack of experience and a perceived lack of technology.

Table 2. Percentage (%) of farmers reporting various aquaculture problems (n=194).

Shrimp Health Problems

Disease was clearly a major problem, with nearly all farmers (95% of separate farms and 98% of mixed farms) reporting outbreaks causing financial losses. Farmers found it difficult to assess the causes, and none reported any success in solving the problem during 1996.

During participatory workshops, farmers clearly recognised shrimp monoculture as being more risky than polyculture. They considered diversification of aquaculture through stocking fish and crabs to be less risky. Farmers also reported that all farms stocked with hatchery-raised postlarvae were affected by disease. However, farmers were unable to identify for certain whether mortality was caused by disease or by other factors, as they had little experience in distinguishing between different diseases. No aquaculture extension was available at the time to provide advice on shrimp disease control.

Shrimp farms based on natural recruitment apparently did not experience such severe problems, but yields were reported to be low. This suggests that recruitment was poor at the time of the disease and raises a number of questions regarding the impact of disease on wild stocks that need to be addressed by research.

Economic Impact of Shrimp Disease

Shrimp disease has become a serious problem in the Mekong Delta of Vietnam, and these very extensive farms were no exception. Whilst it is difficult to estimate the overall economic losses, the figures from the survey reported here extrapolate to an estimate that US$27 to 28 million was lost throughout the delta in 1994. World Bank (WB) estimates are on the order of US$50 million for the same period.

Financial losses from the survey were reported as $732 per affected separate farm and $1,249 per affected mixed farm, figures that indicate the financially serious nature of the problem. These figures, whilst difficult to verify, are close to the annual income of many households. The disease clearly had a major affect on farm profitability, with many farms falling into debt at this time.

The social impacts of shrimp disease were severe in the enterprises, and included problems with increased debt. This situation was made worse by a lack of alternative income. However, food was available from the brackishwater areas. These problems affected the potential of shrimp culture to contribute to poverty alleviation.

Shrimp Disease Investigations

The shrimp disease problems were subsequently diagnosed as being due to viral disease and water quality problems associated with the onset of the rainy season. Disease surveys conducted in 1997 and 1998 revealed that WSSV was simultaneously present in wild shrimp seed and Acetes spp. during January, April and May. Monodon baculovirus (MBV) was present in wild seed all year round, and was detected more often in the separate farming system than in the mixed farming system. WSSV was present in most samples of harvested shrimp, particularly those collected in the rainy season and in the middle of the dry season. MBV was present in harvested shrimp all year round, with greater prevalence in the rainy season. Mass mortalities occurred four times during the one-year sampling period, in January, June, July and October. These were associated with the presence of WSSV at high prevalence and intensity, and also with poor environmental conditions associated with the onset of the rainy season.

The most important conclusion to be drawn from the results of the disease survey was that risk was significantly higher around the peak of the wet season in July and August, and again in the months October, November and December, the middle of the dry season. These peaks in disease occurrence correspond to the two extremes in the water quality regime. In the peak months of the wet season, low pH and rapid changes in salinity are likely to stress shrimp and predispose them to disease, while in the middle of the dry season, above average water temperatures may predispose the animals to disease. These extremes of water quality partly result from the poor design of ponds, most of which are too shallow and do not have adequate water volume to minimise fluctuations in water quality.

Farmer Responses to Shrimp Disease Problems

Generally, the technical support for farmers is very poor. Farmers received some technical training in mangrove forestry, but there was very limited technical support for aquaculture. In dealing with the various problems faced by farmers, extension support is important. The survey questionnaire explored the extent to which farmers had received technical assistance and their sources of technical information. Only 7% of farmers had received a visit from an extension officer with experience in aquaculture, in contrast to mangrove extension, which was available through each of the Enterprises. The most important source of information on aquaculture was other farmers. Farmers are grouped together in local area groups under the management structure of the Enterprise, which could provide an efficient means of information exchange. Although these groups are currently more involved in forest protection, the opportunity for using them as a means of extending aquaculture advice needs to be examined.

Farmers reported that they had limited opportunities to receive aquaculture advice. The Enterprise has no resident aquaculture extension officer, and funds for extension by provincial fisheries/aquaculture staff appear to be very limited. Advanced farmers were reported to have good co-operation with other farmers and often exchange experience, even though there is no official association. Advanced farmers also can provide advice to poorer farmers. Exchange of ideas among farmers was an important source of advice.

When disease occurred, the farmers could only attempt limited actions, mainly emergency harvest. For many, the only option was to take no action.

Development of Management Interventions

Based on the results of the shrimp health survey and associated work on environmental conditions in the mixed farming systems, a series of management strategies were tried and their effectiveness evaluated. As mortalities were related to water quality, improvement in pond design, considered in more detail elsewhere, is a key first step to minimising the risk of mortality from disease. The following recommendations were developed: