Systematic review and meta-analysis of adverse health effects associated with mycotoxin exposure

Mycotoxins, toxic fungal metabolites present in food, are an increasing global health concern expected to intensify with climate change and shifting dietary patterns.

This review systematically identified, appraised, and synthesized primary research on human health effects associated with exposure to single and multiple mycotoxins, aiming to clarify current evidence, uncertainties, and research gaps.

Following the PECO framework, Embase, Cochrane Library, PubMed, Web of Science, and Scopus were searched from inception to May 2025 for studies reporting measured or modelled mycotoxin exposure and human health outcomes. Non-human, mechanistic, review, and grey literature were excluded. Three reviewers independently screened studies, with duplicate full-text assessment. Risk of bias was evaluated using OHAT and certainty of evidence with GRADE. Sensitivity analyses, publication bias assessment, and non-quantitative evidence were synthesized using Cochrane effect-direction plots. Random-effects meta-analyses assessed associations between aflatoxin exposure and seven health outcomes.

Of 55,342 records, 268 studies met inclusion criteria, covering 17 mycotoxin groups and 71 health outcomes. Liver disease, particularly hepatocellular carcinoma, and kidney disease were the most frequently investigated outcomes, with most studies conducted in Africa and Asia. Qualitative synthesis demonstrated predominantly positive associations between mycotoxin exposure and neurological, metabolic, oncological, renal, reproductive, and developmental disorders. Certainty of evidence was very low for all 21 assessed outcomes, reflecting the predominance of cross-sectional designs and substantial between-study inconsistency. Quantitative meta-analyses of 42 studies identified associations between aflatoxin exposure and hepatocellular carcinoma, liver cirrhosis, elevated ALT, and gallbladder cancer.

Evidence supports associations between mycotoxin exposure and multiple health risks; however, heterogeneity in study design, exposure assessment, and outcome reporting highlights the need for more rigorous and harmonized research across diverse populations.