Intentional Food Contamination Research Articles

Consumer Willingness to Pay for Food Defense and Food Hygiene in Japan: Cross-Sectional Study.

In Japan, incidents of falsified expiration dates on popular cookie brands and health hazards associated with frozen Chinese dumplings have raised food safety awareness. To prevent the intentional contamination of food by foreign substances, large food manufacturing companies have adopted the concept of food defense. The aim of this study was to assess people's willingness to pay for food protection measures. In addition, the impact of participants' personalities and considerations regarding their purchase choices on how much they were willing to pay when shopping for food and other products were measured. A questionnaire on willingness to pay for food hygiene and food defense was administered via a web survey and 1414 responses were included in the analysis. Univariate logistic regression analyses were performed with individuals willing and unwilling to pay additional costs as the objective variable and other questionnaire items as explanatory variables. A principal component analysis was performed on 12 questions regarding how much additional money people were willing to pay, and the principal component scores and other questions were examined for implications and other information. Approximately one-third of the respondents stated that they were unwilling to pay additional costs and reported a willingness to consume delivery food even if it contained items that were not part of the original order. The first principal component reflected the extent to which people were willing to pay additional money, and if so, how much. This tendency existed even if the individual foods and amounts varied. The third principal component reflected the amount of extra money that people were willing to pay, which was determined by the amount people had to pay toward food safety measures. Those who answered "zero" were more likely to believe that consumers should not have to pay to ensure food safety. The second principal component reflected an axis separating food defense and food hygiene. Some items not directly related to food were correlated with this axis. In Japan, the concept of food hygiene is well-established and is generally taken for granted. In contrast, the concept of food defense is relatively new and has not yet fully penetrated the Japanese market. Our research shows that people who think that clothing brands provided added value to clothing products may have similar feelings about food defense. In addition, food hygiene efforts to prevent outbreaks of food poisoning are common in Japan and have been established as the basis of food safety. While food defense efforts are spreading, mainly in companies, it is presumed that they are valuable for the general public as supplementary measures to routine (or basic) food hygiene.

Consumer Awareness of Food Defense Measures at Food Delivery Service Providers and Food Manufacturers: Web-Based Consumer Survey Study.

Various stages of the food chain, from production to processing to distribution, can impact food safety. The concept of "food defense" has emerged as a countermeasure against intentional contamination of food with foreign substances. Although knowledge of food hygiene is common among consumers, there are currently no reports of consumer surveys on food defense. This study aims to investigate consumer awareness of food defense and food safety. We analyzed the results focusing on how consumers behave when they find abnormalities in food to further our knowledge on promoting food defense measures. Participants completed a web-based questionnaire that included items related to awareness of food safety and food defense, as well as actions to be taken in cases of food abnormalities, such as contamination by foreign substances, the presence of a bad smell in purchased food, and the inclusion of extra items not selected by the individual. The participants were asked to indicate their preference among the 5 suggested actions in each case using a 6-point Likert scale. Data analysis involved aggregating responses into binary values. Stepwise linear regression analysis was conducted to examine the relationship between selected actions and questionnaire items, such as sex, age, and personality. A total of 1442 respondents completed the survey, and the majority of participants placed importance on food safety when making food purchases. The recognition of each term was as follows: 95.2% (n=1373) for "food security and safety," 95.6% (n=1379) for "food hygiene," and 17.1% (n=247) for "food defense." The percentages of those who answered that they would "eat without worrying" in the case of "contamination by foreign substances," "bad smell," or "including unpurchased product" in the frozen food they purchased were 9.1% (n=131), 4.8% (n=69), and 30.7% (n=443), respectively. The results showed that contacting the manufacturer was the most common action when faced with contaminated food or food with a bad smell. Interestingly, a significant percentage of respondents indicated they would upload the issue on social networking sites. Logistic regression analysis revealed that male participants and the younger generation were more likely to choose the option of eating contaminated food without worrying. Additionally, the tendency to upload the issue on social networking sites was higher among respondents who were sociable and brand-conscious. The findings of this study indicate that if food intentionally contaminated with a foreign substance is sold and delivered to consumers, it is possible consumers may eat it and experience health problems. Therefore, it is crucial for not only food manufacturers but also food delivery service providers to consider food defense measures such as protecting food from intentional contamination. Additionally, promoting consumer education and awareness regarding food defense can contribute to enhancing food safety throughout the food chain.

Methods in food defence: a simple and robust screening for 16 rodenticides by LC-DAD/FLD following QuEChERS–based extraction

Fortunately, the intentional contamination of food or water supplies out of criminal or terroristic motivation is a rather rare event. However, in the face of asymmetric warfare and as the consequences of such an event would be severe, food defence as a necessary supplement to food safety is gaining increased attention. While some progress has been made in developing non-target detection devices, the contamination of food or water supplies using readily available rodenticides may still be revealed only by complex analytical techniques. The presented study therefore aimed to develop a quick and easy screening method for the detection of sixteen globally common rodenticides in foodstuffs. Robust operation with limited personnel and analytical resources were one benchmark to be met by the method, which uses a slightly modified QuEChERS (quick, easy, cheap, effective, rugged, safe) protocol for dispersive solid-phase extraction and subsequent ion-pair chromatography with diode-array and fluorescence detection. Quantification limits were as low as 5 µg/kg with satisfying bias (recovery) and repeatability rates of 77 to 117% and 1.8 to 17.1%, respectively. The developed method provides reliable and robust detection of these deadly poisons at toxic concentrations, which was demonstrated impressively in an improvised assault scenario.

Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021.

SummaryBotulism is a rare, neurotoxin-mediated, life-threatening disease characterized by flaccid descending paralysis that begins with cranial nerve palsies and might progress to extremity weakness and respiratory failure. Botulinum neurotoxin, which inhibits acetylcholine release at the neuromuscular junction, is produced by the anaerobic, gram-positive bacterium Clostridium botulinum and, rarely, by related species (C. baratii and C. butyricum). Exposure to the neurotoxin occurs through ingestion of toxin (foodborne botulism), bacterial colonization of a wound (wound botulism) or the intestines (infant botulism and adult intestinal colonization botulism), and high-concentration cosmetic or therapeutic injections of toxin (iatrogenic botulism). In addition, concerns have been raised about the possibility of a bioterrorism event involving toxin exposure through intentional contamination of food or drink or through aerosolization. Neurologic symptoms are similar regardless of exposure route. Treatment involves supportive care, intubation and mechanical ventilation when necessary, and administration of botulinum antitoxin. Certain neurological diseases (e.g., myasthenia gravis and Guillain-Barré syndrome) have signs and symptoms that overlap with botulism. Before the publication of these guidelines, no comprehensive clinical care guidelines existed for treating botulism. These evidence-based guidelines provide health care providers with recommended best practices for diagnosing, monitoring, and treating single cases or outbreaks of foodborne, wound, and inhalational botulism and were developed after a multiyear process involving several systematic reviews and expert input.

Food Contamination: A Primer

Food is regarded as hygienic and safe for consumption when it does not pose any threat or risk to the health and economy such as sales loss. Food contamination occurs when bacteria or other germs get into food, which can cause food-borne illness. Whilemost food contaminations are accidental, there has been some evidence of intentional food contamination. A major accident infood contamination can cost a company a massive recall that may be devastating to its reputation and profit because it hasserious consequences for the health and wellbeing of people and the planet. This paper aims at providing a primer on foodcontamination, its causes, and prevention

Monoclonal antibody-based sandwich ELISA for the detection of mammalian meats

In order to (1) reduce the risk of intentional or unintentional contamination of foods, (2) better comply with food regulations, and (3) decrease economic loss to the food industry caused by recall, it is necessary to develop reliable methods for the detection of different food adulterants/contaminants. This study was conducted to characterize two mammalian skeletal troponin (sTn) specific monoclonal antibodies (mAbs 6G1 and 8F10), and use them to develop a mAb-based sandwich enzyme-linked immunosorbent assay (ELISA) for the detection of mammalian meats. From our results, both mAbs were positive to porcine sTnI and sTnC but negative to sTnT. The extractability and antigenicity of target analytes in pork were enhanced by the addition of urea and β-mercaptoethanol into the extraction buffer. The optimized sandwich ELISA was specific to heated mammalian meats and was adequate to analyze samples subject to the most severe heat treatment (132 °C/2 bar/120 min). Mammalian fat (10–30%, g/g) did not significantly affect the assay signal. The optimized assay could detect as low as 1% (g/g) of heated mammalian meats adulterated in poultry meats. Overall, this assay has the potential to fight food fraud, comply with food regulations, and decrease food recalls, which may open up new diagnostic methods for the food industry and the food regulatory authorities.

Poziom świadomości konsumentów w zakresie terroryzmu żywnościowego jako przykład współczesnego zagrożenia dla przemysłu rolno-spożywczego

Celem artykułu było zaprezentowanie świadomości konsumentów z zakresu terroryzmu żywnościowego jako nowego zagrożenia w przemyśle spożywczym. Terroryzm żywnościowy to nowe zjawisko, które w XXI wieku stanowi wyzwanie dla przemysłu spożywczego. Polega na celowym skażeniu żywności przy wykorzystaniu substancji biologicznych, chemicznych i fizycznych. Na każdym etapie produkcji żywności może dojść do intencjonalnego skażenia żywności. Do zrealizowania celu zastosowano badania ankietowe, które zostały przeprowadzone z wykorzystaniem portalu internetowego. W badaniach wzięło udział 120 respondentów z Wielkopolski. Na podstawie literatury przedmiotu oraz przeprowadzonych badań ankietowych stwierdzono, iż konsumenci nie są w pełni świadomi, że żywność może być celem ataku terrorystów. Według badanych osób, terroryzm żywnościowy ma charakter globalny i może wystąpić na każdym etapie łańcucha żywnościowego. Z racji, że terroryzm żywnościowy jest zjawiskiem nowym w gospodarce, metody wykorzystywane przez terrorystów oraz potencjalne skutki zagrożenia nie są do końca znane.

Food defence systems as an answer to food terrorism.

Terrorist attacks on critical infrastructures can cause problems to a national stability and functioning. Food and water supply chains are some of the most important infrastructures, and it is the country's (government's) obligation to provide sufficient quantities of food and water to its population. Intentional food contamination can, among other motives, originate from an act of terrorism (with political or ideological motives) with the aim of causing fear (terror) among people. Food defence systems can help assess vulnerabilities, determine mitigation strategies for terrorist attack, estimate risks, and prevent a terrorist attack. Risk assessment and prevention also include control over the production and distribution of potential chemical, biological, radiological or nuclear (CBRN) agents or their related materials. When a terrorist attack occurs, rapid and organised response is essential in terms of determining the type of agent used, managing the diseased, ensuring the functioning of the food and water supply, and the recovery of the infrastructure system under attack. Food defence planning as part of a food counterterrorism strategy should include considerations regarding the global food market and the fact that ingredients are supplied from all over the world (vendor certificates). Preventing terrorist attacks on sources of food and water is a far better option than crisis management once an attack had already been committed, but governments should have a response to any scenario.

Estimate of the annual burden of foodborne illness in nondeployed active duty US Army Service Members: five major pathogens, 2010-2015.

In this study, we estimate the burden of foodborne illness (FBI) caused by five major pathogens among nondeployed US Army service members. The US Army is a unique population that is globally distributed, has its own food procurement system and a food protection system dedicated to the prevention of both unintentional and intentional contamination of food. To our knowledge, the burden of FBI caused by specific pathogens among the US Army population has not been determined. We used data from a 2015 US Army population survey, a 2015 US Army laboratory survey and data from FoodNet to create inputs for two model structures. Model type 1 scaled up case counts of Campylobacter jejuni, Shigella spp., Salmonella enterica non-typhoidal and STEC non-O157 ascertained from the Disease Reporting System internet database from 2010 to 2015. Model type 2 scaled down cases of self-reported acute gastrointestinal illness (AGI) to estimate the annual burden of Norovirus illness. We estimate that these five pathogens caused 45 600 (5%-95% range, 30 300-64 000) annual illnesses among nondeployed active duty US Army Service members. Of these pathogens, Norovirus, Campylobacter jejuni and Salmonella enterica non-typhoidal were responsible for the most illness. There is a tremendous burden of AGI and FBI caused by five major pathogens among US Army Soldiers, which can have a tremendous impact on readiness of the force. The US Army has a robust food protection program in place, but without a specific active FBI surveillance system across the Department of Defence, we will never have the ability to measure the effectiveness of modern, targeted, interventions aimed at the reduction of specific foodborne pathogens.

A MANAGEMENT SYSTEM FOR PREVENTING INTENTIONAL FOOD CONTAMINATION BASED ON RISK ANALYSIS

In today’s globalized world the number of risks in supply chains are increasing and the threats are becoming more complex. All the risks and threats can have a severely negative impact on markets. Some of these threats are terrorism, piracy and theft. Within the food industry, Food Terrorism has gained relevance due to the extreme consequences it may have on both public health and the market. Food Terrorism refers to the intentional contamination of food in any link of the supply chain, which covers everything from production to consumption. The Food Defense refers to the analysis, control and improvement of prevention mechanisms of those attacks; that is, the Food Defense involves a Risks Management. In general terms, this paper focuses on a proposal formulation based on a risk analysis that allows establishing a management system for preventing intentional food contamination and the improvement of the security of the supply chain. Given the recent events in Paris, on November 13, 2015, consideration has also been given to the present situation and the importance of the issue of preventing terrorism.This initial study covers only the theoretical methodological proposal and focusses only on the companies of the alimentary sector of Guanajuato State in Mexico. However, it may extend into a research plan security of food supply chain.

Analysis of paralytic shellfish toxins, potential chemical threat agents, in food using hydrophilic interaction liquid chromatography–mass spectrometry

A novel method for determining paralytic shellfish toxin (PST) profiles in food was developed using a combination of silica and strong cation exchange (SCX) solid phase extraction (SPE) coupled to hydrophilic interaction liquid chromatography–tandem mass spectrometry (HILIC–MS/MS). Besides the risk for natural contamination of seafood and drinking water, PSTs also pose potent threats through intentional contamination of food, due to their high toxicity and the wide distributions of toxin-producing algae. The new preparation method aim to maintain the samples’ original toxin profiles by avoiding conditions known to induce interconversion or degradation of the PSTs. The method was evaluated for PST extraction from water, milk, orange juice, apple purée, baby food, and blue mussels (Mytilus edulis). The extracts were found to produce reproducible retention times in HILIC–MS/MS analysis. When an authentic toxic mussel sample was analyzed using the novel method, saxitoxin and gonyautoxin-3 were identified, in agreement with data acquired using the Lawrence pre-column oxidation high-performance liquid chromatography–fluorescence detection (HPLC–FLD) method. Overall recoveries of the PSTs from tested foods by the novel method ranged from 36% to 111%.

Developing a national food defense guideline based on a vulnerability assessment of intentional food contamination in Japanese food factories using the CARVER+Shock vulnerability assessment tool.

The awareness of food terrorism has increased following the September 11, 2001 terrorist attacks in New York City, United States, and many measures and policies dealing with this issue have been established worldwide. Suspected deliberate food-poisoning crimes have occurred in Japan, although they are not regarded as acts of food terrorism. One area of concern is that the small- to medium-sized companies that dominate Japan's food industry are extremely vulnerable to deliberate food poisoning. We conducted a literature research on food defense measures undertaken by the World Health Organization and in the United States and Europe. Using the Carver+Shock vulnerability assessment tool, eight food factories and related facilities in Japan were evaluated and we found the level of awareness of food defense to be low and the measures inappropriate. On the basis of this evaluation, we developed a set of guidelines that Japanese food companies can use to help develop their food defense strategies and to serve as a reference in considering specific measures.

Inactivation of avirulent pgm+ and Δpgm Yersinia pestis by ultraviolet light (UV-C)

Yersinia pestis is the causative agent of bubonic plague. Though not considered a foodborne pathogen, Y. pestis can survive, and even grow, in some foods, and the foodborne route of transmission is not without precedent. As such, concerns exist over the possible intentional contamination of foods with this deadly pathogen. Here we report the inactivation of avirulent (pYV-minus) strains of Y. pestis by ultraviolet light (UV-C, 254 nm). Two strains of Y. pestis containing an intact pgm virulence locus (pgm+) and strains from which the pgm locus was spontaneously deleted (Δpgm) were tested using cells grown in both logarithmic and stationary phase. The D10 values for inactivation (the UV-C dose required to inactivate one log of bacterial cells) of Y. pestis on the surface of agar plates ranged from 0.69 to 1.09 mJ/cm2. A significant difference was observed between the inactivation of cells of Y. pestis strain Yokohama grown in logarithmic and stationary phases, but no significant difference between growth phase sensitivity to UV-C was observed in Y. pestis strain Kuma. No difference in D10 values was observed between pgm+ and Δpgm strains of Yokohama grown to either logarithmic or stationary phase. A measurable difference was observed between the D10 of Kuma pgm+ and Kuma Δpgm grown in logarithmic phase, but this difference was diminished in the Kuma strains grown to stationary phase. Though strain variations exist, the results showing that UV-C can inactivate Y. pestis cells on agar surfaces suggest that UV-C would be effect in inactivating Y. pestis on food surfaces, particularly foods with a smooth surface.

Tentative food defense guidelines for food producers and processors in Japan.

With increasing global interest in intentional food contamination, expert meetings have been held by the G8, while the U.S. government has proposed policies for preventing food terrorism and intentional contamination. However, Japan has no food defense policy, and some food companies are concerned about an impending terrorism and contamination crisis. We developed a Food Defense Checklist for Food Producers and Processors and published the details on the website. We also developed tentative Food Defense Guidelines for Food Producers and Processors on the basis of the checklist. In this study, we tested the usability of the guidelines through a hearing survey regarding food plants. We also compared the checklist with the implementation manual for the approval system of Comprehensive Sanitation Management and Production Process (the Japanese equivalent of the HACCP). We organized the comments gleaned from the hearing survey and provided a detailed explanation of the guidelines. As the HACCP has been adopted by Japanese food companies, we included both precautionary measures and the HACCP perspective in the explanation regarding the rapid dissemination of information. The guidelines are useful for Japanese food companies, and it is important to disseminate knowledge on this topic and implement food defense measures.

Brucella as a Potential Agent of Bioterrorism

Perception on bioterrorism has changed after the deliberate release of anthrax by the postal system in the United States of America in 2001. Potential bioterrorism agents have been reclassified based on their dissemination, expected rate of mortality, availability, stability, and ability to lead a public panic. Brucella species can be easily cultured from infected animals and human materials. Also, it can be transferred, stored and disseminated easily. An intentional contamination of food with Brucella species could pose a threat with low mortality rate. Brucella spp. is highly infectious through aerosol route, making it an attractive pathogen to be used as a potential agent for biological warfare purposes. Recently, many studies have been concentrated on appropriate sampling of Brucella spp. from environment including finding ways for its early detection and development of new decontamination procedures such as new drugs and vaccines. There are many ongoing vaccine development studies; some of which recently received patents for detection and therapy of Brucella spp. However, there is still no available vaccine for humans. In this paper, recent developments and recent patents on brucellosis are reviewed and discussed. Keywords: Biotechnology, bioterrorism, brucellosis, decontamination, diagnosis, patents, Salmonella typhimurium, polymorphonuclear leukocytes, bioterrorism, bioweapon

Brucella as a Potential Agent of Bioterrorism

Perception on bioterrorism has changed after the deliberate release of anthrax by the postal system in the United States of America in 2001. Potential bioterrorism agents have been reclassified based on their dissemination, expected rate of mortality, availability, stability, and ability to lead a public panic. Brucella species can be easily cultured from infected animals and human materials. Also, it can be transferred, stored and disseminated easily. An intentional contamination of food with Brucella species could pose a threat with low mortality rate. Brucella spp. is highly infectious through aerosol route, making it an attractive pathogen to be used as a potential agent for biological warfare purposes. Recently, many studies have been concentrated on appropriate sampling of Brucella spp. from environment including finding ways for its early detection and development of new decontamination procedures such as new drugs and vaccines. There are many ongoing vaccine development studies; some of which recently received patents for detection and therapy of Brucella spp. However, there is still no available vaccine for humans. In this paper, recent developments and recent patents on brucellosis are reviewed and discussed.

Predicting Psychological Ripple Effects: The Role of Cultural Identity, In‐Group/Out‐Group Identification, and Attributions of Blame in Crisis Communication

Incidents of intentional food contamination can produce ripple effects in consumers such as reduced trust and increased anxiety. In their postcrisis communication, food companies often direct the blame at the perpetrator in an effort to mitigate potential losses and regain consumer trust. The attempt to placate consumers may, in itself, potentially create psychological ripple effects in message readers. This study examined the interacting influence of two message characteristics: identity of the perpetrator of the crime (in-group/out-group membership), and the attribution of blame (reason why the perpetrator committed the crime), with message receiver characteristic (cultural identity) on psychological ripple effects such as blame, trust, anxiety, and future purchase intention. Results indicated that although group membership of the perpetrator was not significant in predicting outcomes for the organization, the attribution communicated in the message was. American message receivers blamed the organization more and trusted it less when personal dispositional attributions were made about the perpetrator. Asian message receivers blamed the organization more and trusted it less when situational attributions were made about the perpetrator. Lowered trust in the company and increased anxiety correlated with lower purchase intent for both American and Asian message receivers. Implications for crisis message design are discussed.

Rapid screening of radioactivity in food for emergency response

This paper describes the development of methods for the rapid screening of gross alpha (GA) and gross beta (GB) radioactivity in liquid foods, specifically, Tang drink mix, apple juice, and milk, as well as screening of GA, GB, and gamma radioactivity from surface deposition on apples. Detailed procedures were developed for spiking of matrices with (241)Am (alpha radioactivity), (90)Sr/(90)Y (beta radioactivity), and (60)Co, (137)Cs, and (241)Am (gamma radioactivity). Matrix stability studies were performed for 43 days after spiking. The method for liquid foods is based upon rapid digestion, evaporation, and flaming, followed by gas proportional (GP) counting. For the apple matrix, surface radioactivity was acid-leached, followed by GP counting and/or gamma spectrometry. The average leaching recoveries from four different apple brands were between 63% and 96%, and have been interpreted on the basis of ion transport through the apple cuticle. The minimum detectable concentrations (MDCs) were calculated from either the background or method-blank (MB) measurements. They were found to satisfy the required U.S. FDA's Derived Intervention Levels (DILs) in all but one case. The newly developed methods can perform radioactivity screening in foods within a few hours and have the potential to capacity with further automation. They are especially applicable to emergency response following accidental or intentional contamination of food with radioactivity.

Use of a Stakeholder-Driven DACUM Process to Define Knowledge Areas for Food Protection and Defense

One of the important areas of vulnerability that has been repeatedly identified following the events of September 11, 2001 is the potential for an intentional attack on America’s food supply. Despite the importance of equipping professionals to protect our nation’s food supply, educators face a scarcity of information on which to base food protection and defense curricula and training development efforts. This research sought to identify a set of knowledge content areas required by food protection and defense professionals. A Developing A CurriculUM (DACUM) process was employed to create a job task analysis that identified duties, tasks, steps, and associated knowledge, skills, and abilities for this occupational category. The knowledge areas identified during the DACUM process and validated through a stakeholder survey were used to frame the program for a training workshop and computer simulation in which participants responded to a mock intentional food contamination event. Results of this process can serve as foundational elements that can be shaped by instructional and curricular design experts to create educational programs in food protection and defense for graduate students and in-service professionals.

Establishing a Milkborne Disease Outbreak Profile: Potential Food Defense Implications

The main objectives of this study were to establish baseline characteristics for milkborne outbreaks, establish an expected milkborne outbreak profile, and identify potential indicators of food terrorism. This study used 1990-2006 data from the Centers for Disease Control and Prevention Annual Listings of Disease Outbreaks and the Foodborne Outbreak Database (FOOD) to establish epidemiologic baseline characteristics for disease outbreaks associated with fluid milk. FOOD data from 2007 were used to qualitatively validate the potential of the baseline characteristics and the expected outbreak profile. Eighty-three fluid milkborne outbreaks were reported between 1990 and 2006, resulting in 3621 illnesses. The mean number of illnesses per outbreak was 43.6 (illness range: 2-1644). Consumption of unpasteurized milk was associated with 55.4% of reported outbreaks. Campylobacter spp., Escherichia coli, and Salmonella spp. caused 51.2%, 10.8%, and 9.6% of reported outbreaks, respectively. Private homes accounted for 41.0% of outbreak locations. Number ill, outbreak location, and etiology were the primary characteristics which could signal a potential intentional contamination event. In 2007, one pasteurized milk outbreak caused by Listeria was flagged as aberrative compared with the expected outbreak profile. The creation and dissemination of expected outbreak profiles and epidemiologic baseline characteristics allow public health and Homeland Security officials to quickly assess the potential of intentional food contamination. A faster public health and medical system response can result in decreased morbidity and mortality.